Authorization to Disclose Health Information

For your convenience, Altitude Family & Internal Medicine provides this online tool for submitting an electronic request for medical record disclosure. By submitting this online form you will ensure efficient processing of your medical record request. The 2000 ESIGN Act (Electronic Signatures in Global and National Commerce) gives the government's stamp of approval on electronic documents such as this. Please be sure to read this authorization in its entirety, complete all portions of the form, and place your signature in the appropriate box using your mouse or touch enabled device.
  • Patient Information:

  • Use ONLY if the person requesting record is NOT the patient, i.e. a legally appointed patient representative or custodian of a minor.
  • Please SEND my information TO:

    The following fields indicate where you would like your medical record to be transferred to. If you are requesting your record from another facility to be sent to our facility, please insert the following information: ALTITUDE FAMILY & INTERNAL MEDICINE, 13402 W COAL MINE AV, SUITE 230, LITTLETON, COLORADO 80127. PHONE (303)730-2167. FAX (303)996-4820.
  • Please OBTAIN my information FROM:

    The following fields indicate where you would like your medical record to be requested from. This would typically be a doctor or facility you have done business with in the past.
  • Medical Record Information Requested:

  • Use ONLY if you selected "specific period of time" above.
  • Use ONLY if you selected "specific period of time" above.
  • If applicable.
  • If applicable.
  • Acknowledgements, Terms, and Conditions

    1. VOLUNTARY AUTHORIZATION. I understand that authorizing the disclosure of health information is a voluntary act except in the case of certain emergencies or legal situations. 2. IMPACT ON MEDICAL CARE. I understand that generally, Altitude Family & Internal Medicine and any other entity covered by the Health Insurance Portability and Accountability Act of 1996, may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization. If this authorization is for purposes of determining enrollment, eligibility, underwriting or risk rating prior to enrollment, not signing or revoking this authorization may impact enrollment or benefit determinations. 3. REVOCATION. I understand that I have the right to revoke the authorization. I understand that my revocation must be in writing, signed, and delivered to Altitude Family & Internal Medicine, Privacy Officer, 13402 W Coal Mine Ave, Suite 230, Littleton, Colorado, 80127. I also understand that my revocation will be valid except to the extent that the person(s) or organization(s) authorized to make the requested use/disclosure have taken action in reliance on this authorization or if this authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest the claim under the policy or the policy itself. If I revoke my authorization, it will not affect any actions already taken by Altitude Family & Internal Medicine or any other covered entities based upon this authorization. 4. REDISCLOSURE. I understand that once my healthcare information is disclosed as I have authorized, it could be redisclosed by the recipient and is no longer protected by Altitude Family & Internal Medicine. Additionally, the information may no longer be protected under health information privacy laws. 5. CONTENT. I understand that Altitude Family & Internal Medicine is only permitted to send the medical records that they the legal custodian of, and that any other records may need to be requested from their specific custodian or source. I understand that I have the right to inspect or request copies of the information that will be used, discussed, or disclosed pursuant to this authorization. 6. SENSITIVE INFORMATION. I understand that information related to alcoholism, drug abuse, mental health, rehabilitation, and/or HIV/AIDS testing or diagnosis may be a part of my medical record. If I wish this information to be released the appropriate section(s) in this form must be marked. I further understand that records related to alcoholism, drug abuse, and mental health may not be disclosed to me if the health care provider determines that doing so would present a risk of adverse or detrimental consequences. In this case I may designate another medical professional to review the record on my behalf. 7. RECORD CUSTODIANSHIP. I understand that when changing primary care providers, once my healthcare information is disclosed as I have authorized, Altitude Family & Internal Medicine is no longer the custodian of my medical record and any further record requests must be directed to my new primary care provider or the custodian of record. 8. MINORS. I understand that if I am apparent making a request for a minor, I will not be shown portions of the medical record to which, by law, a minor may consent to without parental involvement. If I am a minor, I will only be given access to those portions of the medical record that I may legally consent for without the involvement of a parent or guardian. 9. FEES. I understand that pursuant to Federal Regulation and Colorado State Law, there may be a fee for obtaining medical records. Payment of this fee is the responsibility of the requestor and must be paid prior to the processing and delivery of the medical records. 10. STATE AND FEDERAL LAW. I understand that this agreement is consistent with Federal, State, and Local statutes and regulations including but not limited to the Health Insurance Portability and Accountability Act of 1996. I understand that signing this authorization does not specifically cancel any rights that I may have under other state or federal laws. I further agree that reprints or digital versions of this form and of my signature shall be considered valid as the original.
  • Place your signature using your mouse or touch enabled device.