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Patient Authorization for Vibrant Health of Colorado to Release Protected Health Information
Today's Date*
Patient Name*
Date of Birth*

MonthDayYear
I hereby authorize the transfer of my records from Vibrant Health of Colorado to be transferred to: (Please list name of provider or office name to transfer records to)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number*
Please enter a valid phone number.
The following individually identifiable health information:*

All medical recordsDate of ServiceImaging ReportsLab reportsMental Health RecordsRelated to Drug AbuseRelated to Alcohol AbuseHIV Results
Date of Service(s) *
This authorization will expire in 1 year, unless another expiration date is indicated below.

MonthDayYear
Date
When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that Vibrant Health of Colorado has acted in reliance upon this authorization. My written revocation must be submitted to Vibrant Health of Colorado Privacy Officer at 10099 Ridge Gate Parkway, Suite 410, LoneTree, Co. 80124
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Patient Authorization for Vibrant Health of Colorado to Release Protected Health Information