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Colorado Medical Records Release Form 1

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This form is provided by Reproductive Associates of Colorado to authorize the disclosure or release of one person's protected health information.

Colorado Medical Records Release Form 1
Colorado Medical Records Release Form 1
CONCEPTIONS REPRODUCTIVE ASSOCIATES OF COLORADO
www.conceptionsrepro.com
271 West County Line Road 4500 E. 9
th
Avenue, Suite 630 300 Exempla Circle, Suite 370
Littleton, Colorado 80129 Denver, Colorado 80220 Lafayette, Colorado 80026
T: 303.794.0045 F: 303.794.2054 T: 303.720.7887 F: 720.763.9140 T: 303.449.1084 F: 303.449.1039
Mark R. Bush, M.D., FACOG, FACS
Michael S. Swanson, M.D., FACOG
Dana Ambler, DO, FACOOG
REQUEST FOR MEDICAL RECORDS &
PERMISSION FOR RELEASE OF INFORMATION
PLEASE SEND THIS REQUEST FORM TO PREVIOUS PHYSICIAN FOR MEDICAL RECORDS
Records Requested from:
Dr. __________________________________________________________
(Address) _____________________________________________________
_______________________________________________________________
____________________________________________________________________________________________
Last name First name Middle name Maiden name
_____________________________________________________________________________________________
Street address City State ZIP
(____)________________________________________________________________________________________
Telephone
Last name under which records may be found (if different) Birth Date
Please send my records to (check one):
[ ] Send to Littleton Clinic
271 W County Line Rd
Littleton, CO 80129
Phone: 303-794-0045
Fax: 303-794-2054
[ ] Send to Lafayette Clinic
300 Exempla Circle #370
Lafayette, CO 80026
Phone: 303-449-1084
Fax: 303-449-1039
[ ] Send to Denver Clinic
4500 E. 9th Ave #630
Denver, CO 80220
Phone: 303-720-7887
Fax: 720-763-9140
Please send the following items to the address checked above. Please provide a complete copy of all
medical records, rather than a summary. Thank you for your time and promptness.
Records of care from ________to _________ to include anything that could have a bearing on my fertility.
____ Medical records/operative reports ____ Laboratory reports ____ Hysterosalpingogram x-rays and reports
____ Biopsy slides ____ Other (please specify)___________________________________________
I hereby grant permission for release of these records.
____________________________________________________ _________________________________
(Name) (Date)
____________________________________________________ _________________________________
(Witness) (Date)
APPOINTMENT DATE _______________________________
PLEASE RETURN A COPY OF THIS FORM WITH THE PATIENT’S RECORDS
Colorado Medical Records Release Form 1