HIPAA Release Form and Medical Record Request
Doctors Medical Group of Colorado Springs
1022 Fortino Blvd #8597, Pueblo CO 81008 (mailing only)
Tel: 719-531-0409
Complete all sections of this form. Incomplete forms will be considered invalid, and your health information will not be shared.
Section I
I, ___________________________________________, authorize Doctors Medical Group
of Colorado Springs (DMGCS) to share the information specified in Section II with the person(s) or organization(s) listed in Section IV. To be completed by the patient if over 18 years old or parent/guardian.
My address is:_____________________________________________________________
Best telephone contact number:_____________________________________________________
My email address to receive documents as attachments:__________________________________________________
Date of Birth of Patient:______________________________________________________
Approximate dates of DMGCS care:________________________________________________________
Section II – Health Information
I authorize DMGCS to disclose:
● Office patient visit notes, evaluations, testing, and diagnoses
● Excluding the following information (check all that apply)
○ Mental health records
○ Records of communicable diseases (including HIV and AIDS)
○ Alcohol/drug abuse treatment records
○ Genetic information
Section III – Reason for Disclosure - Please detail the reasons why information is being
shared.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Section IV – Who Can Receive My Health Information
I give authorization for the health information detailed in section II of this document to be shared with the following individual(s) or organization(s)
Name: _________________________________________________________________
Organization: ________________________________________________________________
Address: _________________________________________________________________
Telephone:________________________________________________________
Email address to receive records as an attachment: _______________________________________________________________
I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them.
Section V – Duration of Authorization
This authorization to share my health information is valid:
From ___________________ to ___________________
I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:
Annelise Spees MD, DMGCS,1022 Fortino Blvd #8597, Pueblo CO 81008
I understand that: In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data. I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section IV.
Section VI – Signature
Signature: ____________________________________________________ Date:______________
Print your name:
_______________________________________________________________
If this form is being completed by a person with legal authority to act an individual’s behalf, such as a parent or legal guardian or health care agent, please complete the following information:
Name of patient:________________________________________________
Date of Birth:_______________
Name of person completing this form: _____________________________________________________________
Signature of person completing this form: ______________________________________
Describe below how this person has legal authority to sign this form:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________