• Medical Record Release 2022

  • Patients Please Use a Separate Form For Each
    Medical Provider M
    edical Records Request.

  •  -
  • Medical Record (s) are to be released to: 
    Donna Grandi DNP,PMHNP-BC,FNP-BC
    Electronic FAX ONLY (303) 848-4842 (Please No Hard Mail Copies) 

    Reasons for Request
    Continuity of Care

    Patient Consent For Medical Records To Be Released 

  • Requested Information to be Released

    • Most Recent Annual Physical Exam Progress Note
    • Most Recent Medication List and Medication Allergies
    • Most Recent Blood Tests
    • Release mental health, substance abuse, and/or AIDS/HIV information.  
  • I understand and agree to the following four statements per my signature and date below:

    1. I understand and agree that this authorization will expire one year from the date below or on date below.
    2. I understand and agree that I may revoke this authorization at any time by notifying the releasing organization in writing, but my revocation will not affect any releases made or other actions taken before the date of my revocation.
    3. I understand and agree that for use other than referral to a specialist, there may be a fee for services. Third party Life, Accident and Legal Firms requesting patient medical records are required to pre- pay a $75 fee for ancillary and transfer services. After receipt of payment, all medical records will be immediately faxed to said party.
    4. I understand and agree that incomplete information on this form may delay the process of this request.
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