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Patient Records Requests

  • Documents related to patient information are subject to HIPAA will not be released without the consent and signature of the patient.
  • All records requests must be received in writing on the Public Records Request form linked below.
  • Documents will be gathered and ready for review at Platte Canyon Fire Station 2 within fifteen (15) business days (holidays excluded).
  • Proof of identification is required.
  • The cost is $18.53. Platte Canyon Fire may require a deposit for the estimated cost of research and retrieval of documents prior to executing the work. While our goal is to fulfill all requests, we do not create documents that do not already exist.

Submitting a records request

Fill out this form: Authorization to Release Protected Health Information (PHI)
  1. Print and sign the form.
  2. Submit the form (and a copy of proper ID) one of two ways:
  3. MAIL to: P.O. Box 222 Bailey, CO 80421
  4. RETURN the form to the admin office at Station 2 (M–F, 7am–5:00pm).
  5. Payment of $18.53 is required prior to the release of information in one of two ways:
  6. PayPal: PayPal — PCFD PayPal Instructions
  7. Check made payable to “Platte Canyon Fire Protection District”
  8. MAIL to: P.O. Box 222 Bailey, CO 80421.
  9. Or: SUBMIT the check to the admin office at Station 2 (M–F, 7am–5:00pm).

How to pay online via PayPal:

  1. Log into PayPal.
  2. Select “MONEY” from the top bar.
  3. Ensure you are on the “SEND” money page (rather than “REQUEST” money page).
  4. Enter PCFPD’s account email: plattecanyonfire80421@gmail.com.
  5. Enter payment amount of $18.53 (per request).** In the note section, enter Records Request: <Patient Name>. **
  6. Select “SEND”.

For additional questions, please contact us (303) 838-5853.