Forms

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Medical Records

Please use the form below to request copies of your child’s medical records. Patients over the age of 18 must request their own medical records. Turnaround time will depend on the current volume of requests, but please anticipate  5-7 business days.

Please Note: A fee will be charged for printed records intended for personal, legal or insurance company use. No fee will be charged to securely email or fax records.

Please click here to print the authorization form needed to request copies of your child’s medical records. You may drop off or mail this authorization form to any of our locations or fax to (970) 416-6299. A copy of the requesting person’s picture ID is required for medical records requests.

School/Camp/Daycare Forms

  1. 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.
  2. 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.
  3. Turnaround time will depend on current volume of requests, but please anticipate 5-7 business days.
  4. 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.
  5. 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.

School, Camp Or Daycare Form Upload ONLY:

Patient Name(Required)
MM slash DD slash YYYY
Contact Name(Required)
Address
Max. file size: 50 MB.