Authorization for Release of Medical Records

Requests are completed within 14 business days of submitted request.

Please correct the errors described below.
Name (First, Last)

As of 12/23/2024 - Attestation Regarding a Requested Use or Disclosure of Protected Health
Information Potentially Related to Reproductive Health Care

When a HIPAA covered entity or business associate receives a request for protected health information(PHI) potentially related to reproductive health care, it must obtain a signed attestation that clearly states the requested use or disclosure is not for the prohibited purposes described below, where the request is for PHI for any of the following purposes:

  • Health oversight activities
  • Judicial or administrative proceedings
  • Law enforcement
  • Regarding decedents, disclosures to coroners and medical examiners

If you are seeking PHI related to any of the purposes noted above, please complete this Attestation and PHI Request Form instead:

https://hushforms.com/ignitecounselingcolorado-6260

Your information will be encrypted.

Loading...