Medical Records Request

Records requested *

Select at least one.

Send records to *

Copies sent to another medical office are free.

I authorize Rocky Mountain Internal Medicine to release the medical records described in this request. I understand this form is a written request that will be kept in the patient chart, that a signed authorization and photo ID may be required, and that the office will contact me to complete this request. I understand that copies sent to another medical office are free, and that personal copies may be subject to fees under Colorado law. *

Patient information

Who is making this request? *

Records requested *

Purpose of this request *

Send records to *

Delivery method *

Authorization *