Medical Records and Health Form Requests
Medical Records Requests
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 Requests
**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 here.
Before you request a health form, please note:
Patient must be current on their well care visits in order for a form to be completed. If patient is over the age of 3, a well care visit within the last 12 months. If patient is less than 3, a well care visit per AAP guidelines. Click Here to view the Well Care Visit schedule or call our office at (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.
3. Mailed to our East Elizabeth office located at 1200 East Elizabeth, Fort Collins CO. 80524.
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 (from Square or Squareup.com) 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.
Form Charges
Free
Completed at time of well care visit
- Basic forms
- Non-Complex forms
$10 Basic Form
7-10 business days turnaround, includes up to 2 requests
- Daycare Health forms
- Sports Physical forms
- Medication Release forms (1-5 Meds)
- Camp forms
$20 Complex Form
- Family Medical Leave (FMLA) Forms
- Scuba Diving Forms
- Overseas Travel Forms
- Medication Release Forms (5 or more)
- Other forms per staff discretion
$40 Rush Form
- Basic forms only
Health Form Requests
Below are the most commonly requested forms. If your form is not listed, please select the “Upload A Form Not Listed”.
Medication Authorization & Release
Authorization and Release For Administering Medicine to Student at School or School-Sponsored Activity
Click here to fill out the Medication Authorization & Release
2023-2024 PSD MS Sports Form
2023-2024 Middle School Physician Certification of Student Fitness for Athletic Participation
Pre-Participation Physician Clearance
CHSAA Pre-Participation Physical Evaluation
Click here to fill out the Pre-Participation Physician Clearance
Colorado Asthma Care Plan
Colorado Asthma Care Plan and Medication Order for School and Child Care Settings.
General Health Appraisal Form
General Health Appraisal Form
2023-2024 PSD High School Athletics Form
2023-2024 High School Physician Certification of Student Fitness for Athletic Participation
Click here to fill out the 2023-2024 PSD High School Athletics Form
Upload a Form Not Listed
Give us some basic information and upload a blank copy of a form you need completed
Health Form Request FAQS
I can't find the email with my invoice and form.
An invoice and your completed formwill be emailed from Square or Suareup.com and not The Youth Clinic. You may need to check junk or spam emails folders for your form. Once received be sure to mark email “not junk” to receive future emails to your primary inbox.
Why are you now charging for health forms?
Health forms completed outside of the well care visit now require us to assess a nominal fee for completion as we receive a very large volume of requests daily that requires additional staff and time and expertise. We spend a great deal of time before we apply a signature to any form, reviewing charts, current well visits and medications, and want to continue offering a high level of customer service while giving adequate time and attention to each request.
Which health forms are free at my Well Care Visit?
You will receive a general health form and/or sports physical form and any required medication releases at your well care visit for free. For convenience and future access, these forms can be printed and/or pushed to your patient portal (MHC- My Health Connection). This will only be an option for patients who have a current active portal account. You then will be able to access and reuse forms sent to your patient portal for those times you might need a second or third copy during your current well care year.
If you currently do not have a My Health Connection portal account, please click here for more portal information and how to sign up for an account.
What are the charges for forms completion?
Costs range between $10-$20 for Basic Forms and Complex Forms and $40 for expedited requests (this option is only available for Basic forms).
How do I pay for my health form request?
When your form has been completed you will receive an invoice via email (regardless of how you submitted your form for completion).
If you requested your form electronically, your returned form will be in an attachment to the the invoice and you will need to scroll down to the bottom of email to locate the form.
If you dropped off your form at the E Elizabeth office or mailed in your form, you will receive an email invoice and notification your form is ready for pickup or has been mailed as requested.
Payment is due upon receipt.
Check your Junk/Spam email folders! Your invoice and form will come from JotForm and you may want to add noreply@jotform to your email contacts and/or adjust your email spam filter settings to allow these emails to come into your inbox.
What hasn’t changed in the Forms Request Process?
A current/up to date well care visit is needed to complete health forms. For patients 3 and older a well care visit within the past 12 months. For patients under 3 we follow current AAP guidelines, click here for the well care visit schedule.
Our staff will continue giving adequate time and attention to each request and notifying parents with any issues that arise during the form’s completion process.
Completed forms will be returned to parent/patient/guardian via secure email or available for pick up at E Elizabeth office.
How do I know if my form is complete/Can I call and check on the status of my form?
When you receive your emailed invoice you will know your form has been completed. It is preferred that you do not call to check on status of your form as that takes additional time away from forms being completed by our dedicated staff. Please anticipate your form to be completed no later than 10 business days (not including weekends and holidays).
If you requested a Rush Health Form, you will receive your form by the end of the next business day and after the $40 rush fee has been paid.
Check your Junk/Spam email folders! Your invoice and form will come from JotForm and you may want to add noreply@jotform to your email contacts and/or adjust your email spam filter settings to allow these emails to come into your inbox.
What is the E Elizabeth’s office (1200 E Elizabeth St) availability to drop off health form requests?
Mon- Thurs 8am-4pm
Fri 8am-2pm
Website online requests are available 24 hours a day 7 days a week