Turnaround: Requests are processed within 14 business days of receipt of this signed form and payment received if indicated. Records are not released until reviewed and approved by Dr. Knies. No charge: If your records are sent directly to another physician, clinic, or medical facility for your continued care, there is no fee. We only need the receiving facility's name and address below. Please allow 14 business days to send the documents. 

Fees for all other requests (Colorado statutory maximums, C.R.S. 25-1-801 and 25-1-802): First 10 pages — $18.53 flat fee Pages 11 through 40 — $0.85 per page Pages 41 and over — $0.57 per page Records stored on microfilm — $1.50 per page Radiographic studies such as X-ray or imaging — actual cost of reproduction Certification of records, if requested — $10.00 Actual postage and electronic media costs, such as a CD or flash drive, are added when used An invoice is sent once the page count is known. Payment is required before records are released.

Lab requests (same turnaround time applies): At the discretion of the office, we can provide a single lab set copy up to 4 pages at no charge one time. For additional lab results and tracking, please request access to the lab portal. 

Authorization: I authorize Rose Injectables to release the records specified above to the person or organization listed. I understand that I may revoke this authorization at any time in writing, except where action has already been taken based on it; that this authorization is voluntary and is not required in order to receive treatment; that once records are disclosed to a third party they may no longer be protected by HIPAA; that I may be asked to present valid government-issued photo ID; and that I am the patient or am legally authorized to sign on the patient's behalf. Unless I enter a different date below, this authorization expires one year from the date I sign it.