Any request for medical records must be written, and a copy of the request must be retained in the individual patients chart.
If you would like to request a copy of your medical records, or would like to request privacy of your medical records, please fill out the forms below and fax them to your primary office.
Copies for medical records that will be sent to another medical office are free.
Please take note of the following Colorado Med Fee Law in regards to the fee charged for copying the medical records you have requested.
Colorado Law: 6.C.C.R. 1011-1, CHAPTER 2, PART 22.214.171.124
Number of Pages
|1 – 5||Free|
|6 – 10||$14.00|
|11 – 40||$14.00 + 50¢ per page|
|41 or more||$29.00 + 33¢ per page|
Form 1: Release of Medical Records TO RMIM
Form 2: Release of Medical Records FROM RMIM
Form 3: Request for Privacy/Non-Release of Medical Records
Form 4: HIPAA 3rd Party Authorization Form – English
Form 5: HIPAA 3rd Party Formulario de Autorizacion – Spanish