720 848 5551-2026

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The document is an authorization form from the University of Colorado Hospital allowing the release and/or obtaining of a patient's medical information. It includes sections for patient details, information to be reviewed, purpose for the release, and consent acknowledgment. The form emphasizes the voluntary nature of the authorization, potential costs for copying records, and the patient's right to revoke consent.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient Name(s) in the designated field. Ensure that you provide accurate and complete names for proper identification.
Fill in the Social Security Number and Date of Birth fields. This information is crucial for verifying patient identity.
In the 'OBTAIN FROM' section, specify the releasing facility's name and address. Similarly, complete the 'RELEASE TO' section with the receiving entity's details.
Select the information you wish to review by checking the appropriate boxes under 'INFORMATION TO BE REVIEWED'. You can choose options like Emergency Room Report or Discharge Summary.
Indicate the purpose for this release by checking one or more options provided, such as Continuity of Medical Care or Personal Use.
Finally, sign and date the authorization at the bottom of the form. If applicable, include your printed name and relationship to the patient.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is UCHealth public or private?

The U.S. Department of Health and Human Services (HHS) comprises multiple operating divisions and agencies within the U.S. Public Health Service and three human services agencies.

What is the #1 hospital in Colorado?

UCHealth University of Colorado Hospital in Aurora. Photo: UCHealth. For the 14th consecutive year, UCHealth University of Colorado Hospital on the Anschutz Medical Campus in Aurora is the No. 1 hospital in the state, according to this years U.S. News rankings.

Is healthcare part of a government agency?

It is a joint operating company between the University of Colorado Hospital Authority (a state government agency) and Poudre Valley Health.

Who is the parent company of UCHealth?

While UCH is a separate entity from the University of Colorado, were part of the University of Colorado campus system, which operates under a total learning environment mission. We are directly linked to the graduate health sciences schools of the University of Colorado Denver through joint and clinical appointments.

Is UCHealth the same as Anschutz?

If your provider has a designated medical records department, contact them directly. Provide any reference numbers, confirmations, or details you received when submitting your request. It will help your provider quickly locate your file.

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Is UCHealth a government agency?

It was recreated in 1991 as the University of Colorado Hospital Authority as a government agency. University of Colorado Health was formed on January 31, 2012 (doing business as UCHealth since 2014), as a joint operating company between the authority and Poudre Valley Health (of Poudre Valley Hospital).