Medical Records Request

Release of Information

In compliance with the Colorado Open Records Act, we make all records available to the public unless they are protected from disclosure by state or federal statute, court order, or if disclosure of such records would be contrary to public interest.

A patient, or his/her legal representative, may obtain a copy of their billing and or medical records, or have copies sent to another individual or entity, such as an insurance company or attorney.

Please choose an option below for further instructions:

Patient Request | Attorney / 3rd Party Request (for Billing Records)

Patient Records Requests

• Documents related to patient information are subject to HIPAA will not be released without the consent and signature of the patient.

• All records requests must be received in writing on the Public Records Request form linked below.

• Documents will be gathered and ready for review at Platte Canyon Fire Station 2 within fifteen (15) business days (holidays excluded).

• Proof of identification is required.

• The cost is $18.53. Platte Canyon Fire may require a deposit for the estimated cost of research and retrieval of documents prior to executing the work. While our goal is to fulfill all requests, we do not create documents that do not already exist.

Submitting a records request

1. Fill out this form: Authorization to Release Protected Health Information (PHI)

2. Print and sign the form.

3. Submit the form (and a copy of proper ID) one of two ways:

   1. MAIL to: P.O. Box 222 Bailey, CO 80421

   2. RETURN the form to the admin office at Station 2 (M–F, 7am–5:00pm).

4. Payment of $18.53 is required prior to the release of information in one of two ways:

   1. PayPal: PayPal — PCFD PayPal Instructions

   2. Check made payable to “Platte Canyon Fire Protection District”

      1. MAIL to: P.O. Box 222 Bailey, CO 80421.

      2. Or: SUBMIT the check to the admin office at Station 2 (M–F, 7am–5:00pm).

1. Log into PayPal.

2. Select “MONEY” from the top bar.

3. Ensure you are on the “SEND” money page (rather than “REQUEST” money page).

4. Enter PCFPD’s account email: plattecanyonfire80421@gmail.com.

5. Enter payment amount of $18.53 (per request).

   ** In the note section, enter Records Request: <Patient Name>. **

6. Select “SEND”.

For additional questions, please contact us (303) 838-5853.

Attorney or 3rd Party Records Requests

PCFD requires a completed and signed HIPAA Compliant Authorization for Use and Disclosure Form before releasing any documents to anyone other than the patient.

You may submit your own form or download one: HIPAA ComplCompliant Authorization for Use and Disclosure Form.

1. Complete an authorization form in its entirety.

   1. Please ensure the form is signed and dated by the patient or patient representative.

   2. If a patient representative signs the form, please ensure any necessary legal documents accompany the request (ex., Executor of Estate).

2. Submit request via ChartSwap.com using the following steps:

   1. Register at http://www.chartswap.com/register as a Record Requestor

   2. Sign in and Search for a Provider, Enter Request Details, then Upload Supporting Documents.

   3. Once your request has been reviewed and records are available, you will receive a notification and invoice which you can pay with a check or credit/debit card.

   4. Please contact ChartSwap directly at 855-879-7927 if you need to register more than one user or if you would like to schedule training.

*Please allow up to 15 days to process and fulfill the request. If you have any questions, please contact PCFD at 303-838-5853.

*Attorney (or other 3rd Party) Requests for Billing Records received via email, fax, or mail, will be uploaded to ChartSwap and worked accordingly. Requesting outside of ChartSwap could result in further delay of fulfillment of your request.