Medical Records Request

Please fill out the form below and allow up to 7 days to process all medical records requests.

LEGAL, DISABILITY, & All non-patient or provider requests for medical records must be faxed to 303-790-2810

Neuropsychological Testing Records Request

*If you are requesting records for Neuropsychological testing please make sure to select Neuropsychological testing on the medical records form. We cannot release the records unless this is specifically requested. Also please be advised that these reports can only be faxed or mailed they cannot be received by email.*

Medical Records Fees

Medical records fee Schedule

$25.00 Per form to be completed by a provider (Max fee $75)
$18.53 for the first 10 pages
$0.85 per pages 11-40 pages
$0.57 per page after 40 pages.
$15 for Itemized bills without records

Patient Requested Records & Forms fee Schedule

$25 per form max of $75 (FMLA, Disability, etc)
$25-$75 fee for letters depending on information and research required (determined by provider)
Medical records no fee

Notice

Medical records can take 5-7 business days to process, if you need expedited requests a special handling fee of $15 will be charged

Notice

We are unable to send records via electronic media (flash drives, CDs, DVDs, etc.) and if received these requests will be sent back denied or requesting an additional method to send.

REQUESTED RECORDS FROM:

Rocky Mountain Neurology, PC
5975 S Quebec St #150, Centennial CO 80111
Phone 303-790-8899
Fax 303-790-2810

REQUESTED RECORDS FROM:

Rocky Mountain Neurology, PC
5975 S Quebec St #150, Centennial CO 80111
Phone 303-790-8899
Fax 303-790-2810

SEND REQUESTED RECORDS TO:(Required)

PLEASE SEND THE FOLLOWING:(Required)

All progress reports

EMG/EEG/VEP results

Lab tests

MRI results

Neurobehavioral/

Neuropsychiatry testing

ALL RECORDS*

Other

* Please note to provide Neurobehavioral/Neuropsych results, the Neurobehavioral/Neuropsych line MUST be checked.

The purpose of this release is for medical treatment. This authorization will expire one year from the date it is signed. I understand that: 1) I have the right to revoke this authorization in writing, but if I do, it will not have any effect on actions taken prior to the date that written revocation is received; 2) signing this authorization is voluntary; 3) the information used or disclosed to someone who is not a health care provider or a health plan may no longer be protected by federal privacy regulations and may be forwarded by that party without your consent; 4) I am aware and authorize records disclosed containing sensitive information including use or treatment with: alcohol/drug abuse, mental health, genetics, AIDS/HIV; 5) I may have a copy of the information disclosed.

PATIENT INFORMATION

Full Name(Required)

Patient DOB(Required)

Patient or guardian signature(Required)

Send email copy to:(Required)

Enter Email Confirm Email

Please be advised that if you are requesting a copy of your records to be received by email that these will be sent by secure email from RMN@MDofficemail.com and you will need to enter a password to be able to open the attachment. Also just a reminder that Neuropsych testing reports can not be sent by email only by mail or fax.

Release Request Forms

Authorization for Release of Medical Records to Rocky Mountain Neurology

Authorization for Release of Medical Records to Another Doctor or Facility

Medical Records Request

Neuropsychological Testing Records Request

Medical Records Fees

REQUESTED RECORDS FROM:

PATIENT INFORMATION

Release Request Forms

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