The records department will be available until January 19, 2018 to provide copies of medical records to patients and other third-parties. All requests must be submitted in writing by filling out the “Authorization to Release Information” form. Click here to access the form. Due to federal and state confidentiality statutes, a release of information is required in order to acknowledge that a person whose records are being requesting ever was or is a patient with Arapahoe House.
The following are items needed in order to fulfill your request:
- Copy of valid state or federal issued picture identification (ID) belonging to the patient in order to verify signature
- Valid signed authorization to release protected health information (ROI) form. Check all applicable boxes for what information you would like to receive and the intent of your request.
In the "to whom" section of the ROI form:
- If the ROI is to yourself, please print “self” for organization/individual and “self” for relationship
- If the ROI is to a treatment providing agency, the name of the organization must be written in the “to whom” designation. An address and contact number must be provided
- If the ROI is to a non-treatment providing agency, the name of the organization AND the name of the specific individual(s) who is receiving the records must be written in the “to whom” designation. An address and contact number must be provided
- An ROI cannot be a blanket request for the entire treatment record. Please specify what you are requesting to be released. If “other” is selected, it cannot be left blank.
More about the ROI form:
- Please specify how you would like the records to be sent to you (or to the entity identified in the ROI) in the MEDICAL RECORDS REQUESTS section of the ROI
Fees may be applied to your request (CRS § 25-1-801(5)(c)(A) (2016)). Payment must be provided before any medical records will be released. An invoice will be provided to you with details on how to make a payment and the total for your request once we receive the above listed documents.
- No fees are applied for a DUI/DWAI Report (DRS).
- No fees are applied for active patients and patients last seen within 30 days of the request
- No fees are applied for requests by coroners
- No fees are applied for requests to/from other treatment agencies for continuing care
- No fees are applied for requests to/from legal entities that have referred the patient into treatment with Arapahoe House
- No fees are applied for requests falling under the “Laura Hershey Disability Support Act” for first copy
- Other exceptions may apply
If you have any questions, please feel free to contact us at 303-412-3710 or email us at firstname.lastname@example.org. Otherwise, please forward the competed form and copy of ID to email@example.com, fax to 303-412-3362, or mail to: Arapahoe House, Health Information Department, 8801 Lipan St., Thornton, CO 80260.