Patient Forms

Medical Records

Please click here to print the authorization form needed to request copies of your child’s medical records. A valid photo ID, of the legal guardian/parent or patient themselves if 18+ is required for release of medical records. Patients over the age of 18 must request their own medical records. Once the form is complete, please choose ONE of the following options:

Drop off the authorization form at any of our locations
Mail the authorization form to The Youth Clinic 1200 E. Elizabeth Street, Ft. Collins CO 80524 location
Fax to (970) 416-6299

Our turnaround time is typically 7 business days.

Fees for Medical Records Requests are as follows:

To Patient or Legal Guardian: My Health Connection portal delivery is free (all pages). Paper Delivery: 1-10 pages are $6.50, 100 or more pages delivered electronically only.
To Third Party recipient: $18.53 (retrieval fee for pages 1-10) plus $0.85 (each pages 11-40) plus $0.57 (each page over 40).

Patient Health Forms Request

**New Health Forms Request & Return Process Effective 5/1/2023**

Health forms requested and completed outside of your child’s well care visit will be subject to a fee depending upon the complexity of the form (see fee schedule below).

Common health forms may already be available through your child’s My Health Connection portal account.

Immunization Records may be requested for free through the Colorado Immunization Information System’s (CIIS) public portal.

PLEASE NOTE – The email or phone number you enter into the Public Portal search screen must match what is on the patient’s CIIS profile. If a patient’s contact information is not in CIIS, the Public
Portal will not work. Please review the CDPHE Instructions here before attempting to access immunizationj information. You can access the Colorado Ummunization Information System Portal here.

Before you request a form, please note:

Patient must be current on their well care visits in order for a form to be completed. Click Here to view the Well Care Visit Schedule or call our office (970)267-9510 to check if your child’s well care is up to date.

Options for Health Form Requests:

1. Electronically requested by completing form below and uploading any needed form.

2. Dropped off in person at the E Elizabeth office location.

We no longer accept health form requests via voicemail or FAX.

Don’t have a form? No problem, commonly requested fillable forms are also an available option for selection below.

Options for Receiving Completed Health Forms:

1. Electronically by secure email.

2. Pick-up at the East Elizabeth location. At this time, the E Elizabeth office is only location available for in person form requests or pick up of completed forms.

How do I pay form completed forms? An invoice will be sent with completed forms and due upon receipt.

Parents/patients/guardians are responsible for returning completed health forms to child’s school, daycare, camp, etc.