Authorization to Release Records

The Genesee Fire Protection District (GFPD) has adopted a Standard Operating Procedure for Open Records Requests (“Policy”), a copy of which may be obtained from GFPD’s administrative offices. All records requests and GFPD’s responses must comply with the Policy; the Colorado Public (Open) Records Act, C.R. S. § 24-72-201, et seq; and all other applicable law. GFPD will charge fees for it’s responses to a request as provided in the Policy. Please list the document you are authorizing for release with as much specificity as possible. If known, include the type of document, a date or date range, the specific matter, and the names of the person or location. Please attach additional pages if more space is needed. you must specifically authorize the release of records relating to due or alcohol abuse, child abuse, HIV status, genetic testing, sickle cell anemia, mental health records. A separate authorization is required for the release of psychotherapy notes. CRS 24-72-203 (3)(b) The date and hour set for the inspection of records not readily available at the time of the request shall be within "reasonable" time after the request. As used in this subsection (3), a "reasonable time" shall be presumed to be three working days or less. A finding that extenuating circumstance exist shall be made in writing by the custodian and shall be provided to the person making the request who the three day period. Expiration: Unless earlier revoked, this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, on the date I become an adult according to state law. Revocation: I have the right to revoke this authorization in writing at any time, except to the extent that action has been taken based on this authorization. Patient Rights: I understand I have a right to a copy of this authorization. I have the right to inspect or copy the information to be disclosed as provided in 45 CFR 164.524. I have the right to inspect or amend my medical records as provided in 45 CFR 164.526. I have a right to an accounting of the use and disclosure of my health information to any third party as provided in 45 CFR 164.528. Re-disclosure: I understand that any disclosure of protected health information carries with it the potential for unauthorized re-disclosure, and may no longer be protected by federal confidentiality rules.

Electronic Signature