Step 1: Download and Fill Out the Form
We are happy to help you request copies of medical records. To successfully request medical records, you must download and properly complete an authorization form. After we receive your completed form, we can release your medical records.
Download Authorization Release Form (English)
Download Authorization Release Form (Spanish)
Autorizació n para el uso o divulgación de información médica protegida (PHI)
*The document is available as a printable PDF file using Adobe Acrobat. If you do not already have an Adobe Acrobat Reader, download a free copy now.
Step 2: Make Sure Your Form is Correct
To expedite your request, we assembled these tips to help you properly complete your form.
Make sure your form:
- Is properly addressed to the facility being asked to release the information.
- Has the address of the facility or person receiving the information.
Be sure your form has the patient’s:
- Full name, including previously used names.
- Date of birth.
- Social Security number.
Additional necessary information:
- The information and date(s) of service you want released.
- How much information: Pertinent records may include a discharge summary, history and physical, test results, an emergency department report, and any consultations; all records include all vitals and large amounts of routine documentation.
- The reason you want the information released.
- Instructions on whether you want to pick-up the information or the appropriate mailing information.
- The date of your request.
- The patient’s signature.
If the patient is unable to sign the request form due to a physical or mental disability, a guardian or court-named personal representative may sign for the patient. If the patient has no guardian or personal representative, the individual with medical power of attorney may sign for the patient. You must provide appropriate legal documentation with the request form if the patient is unable to provide their own signature.
We regret that we cannot accept digital signatures.
While we can provide medical information and records, we cannot provide copies of birth certificates. For a copy of a birth certificate, please contact the Colorado Department of Public Health and Environment at 303-692-2200.
Step 3: Submit Your Request Form
You can send your request to us through fax, mail, email, or in person. If you email the form, it must be attached as a scanned document.
Good Samaritan Medical Center
Attn: Health Information Management
200 Exempla Circle
Lafayette, CO 80026
Please note, that when you are sending your information to us by email, there is some level of risk that the information in the email could be read by a third party. If you can encrypt the document prior to attaching it to the email, you can then call to let us know the password at 303-467-4046.
Hours of Operation:
M-F; 7:30 a.m. to 4:15 p.m.
Please contact us if you have any additional questions or need further assistance.
We will fulfill your medical records request within 7 to 10 business days, and we will inform you if we experience an unexpected delay.
We may apply fees or charges in accordance with SCL Health policies, but we will notify you of any applicable fees before we process your request.
For additional questions, please call 303-467-4046 or email EH-CROI@sclhs.net.