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).
- Blank forms will not be accepted. Please complete the form below in its entirety (patient info, names of medications and doses, etc.). Blank forms will be returned unsigned.
- Due to HIPAA and best privacy and security practices, we will return forms via mail or place for pickup at one of our 4 office locations. Faxing and emailing are not secure methods of transferring personal health information.
- Turnaround time will depend on current volume of requests, but please anticipate 5-7 business days.
- No form will be completed unless a Well Care Visit has occurred in the last 12 months (an office visit or medication check will not be considered). Please call our office and verify the date of the last Well Care Visit if you are uncertain prior to form submission.
- Forms to be completed may be mailed to our Elizabeth Office at 1200 East Elizabeth St., Fort Collins, CO 80524, dropped off at any one of our four office locations, or uploaded here online. For uploads, we will only accept patient forms (for schools, daycares, etc.). Please do not upload other office forms such as medical records, registration paperwork, insurance, or new patient forms. Please note, we will only return your submissions by mailing them to your home address on file or through in-person pick up.