Information Release Form
Please fax completed form to (303) 673-9703
Please read the following for information regarding Release of Information.
- Centennial Peaks Hospital (CPH) will act upon a properly completed request within 7-10 business days. If the chart is in storage, a delay may be encountered. If the request cannot be fulfilled, the requestor will be notified.
- The minimum necessary for the stated purpose shall be requested.
- There is a charge for copies to be sent, unless the information is going to a continuing care provider for the purpose of continuing care. Charges for copies of records are regulated by State law (C.C.R. 1011-1, Chapter 2, Part 18.104.22.168), and are as follows: $14.00 for the first ten (10) or fewer pages, $0.50 per page for pages 11-40, and $0.33 per page thereafter, plus postage.
- CPH recommends that requests for Attorneys, Insurance Companies, Social Security Disability Offices, and the like come directly from the entity to receive the request. This prevents delays.
- This authorization is voluntary and may be revoked at any time, except in the event that the request has already been completed by CPH or its designee. Revocation must be in writing as provided for on this form or in letter format (written).
- Patients 15 years of age and up may seek treatment on their own at this facility, thus, we require authorization. Please see the physician if there is a problem.
- Those entities receiving health information are informed not to re-disclose confidential health information, however, once a request is completed CPH has no control over how the information is used or disseminated. Confidentiality of alcohol and drug abuse health records is protected by Federal Law. By authorizing this request to release health information, the undersigned releases the above parties from any liability which may result from furnishing the information released or requested.
- Refer to the Notice for Privacy Practices regarding authorized disclosures.
(If Centennial Peaks Hospital has asked for this authorization, the patient receives a copy of the authorization)