Your Medical Records
Patients or authorized health care providers may request copies of patient health records. To request copies of your immunization records, most recent physical or lab results, simply complete our secure form, and click “submit.” You will receive a confirmation that we have received your request. We will provide rapid access to your records as required by federal law. If you choose to pick up your records, a member of Clinica’s staff will contact you when they are ready.
How to Request Medical Records
Requesting medical records from Clinica is easy!
Click the button for either the English or Spanish form. Provide the required information, and click submit.
•English Medical Records Request Form
•Spanish Medical Records Request Form
FAX NUMBERS MEDICAL CLINICS
Lafayette Clinic Fax: 303.926.0363
Pecos Clinic Fax: 303.650.6830
People’s Clinic Fax: 720.565.4250
Thornton Clinic Fax: 720.929.1421
Westminster Clinic Fax: 303.546.4000
FAX NUMBERS DENTAL CLINICS
Pecos Dental Clinic Fax: 720.206.0437
Thornton Dental Clinic Fax: 720.207.0171
Your Responsibilities As Our Patient
FOLLOW CLINICA RULES — Behave respectfully toward Clinica Family Health staff as well as other patients. Please assist with the control of noise and observe the no smoking policy and all other posted building regulations.
INFORM REGARDING YOUR HEALTH — Please give full and honest information regarding your past and present health information, including any known allergies and/or sensitivities.
MEDICATION SAFETY — Please keep and share information on all medications you take, including those from other health care providers, over-the-counter medications and dietary supplements. If you currently take medications, please bring all your medications to each appointment. Many health care mistakes are made because patients don’t tell their health care provider about all the medications they take.
REPORT CHANGES — Report any changes in your condition, symptoms, and allergies to your provider.
REPORT EMERGENCIES — Should you receive emergency care from another health care provider, emergency room, or urgent care center, please contact Clinica during normal business hours as soon as possible to share this information.
PARTICIPATE IN YOUR OWN HEALTH CARE — If you do not understand your provider’s instructions or have any questions, please ask your provider to explain more clearly or ask that someone else assist in explaining the instructions to you.
REPORT SAFETY CONCERNS — We encourage you to help us by reporting any concerns you have about your or your family’s safety at Clinica. Report concerns to a staff member or ask to speak to a manager.
FOLLOW INSTRUCTIONS — Follow the instructions and health care plan that you and your provider have agreed on. Failure to do so may worsen your condition.
MANAGE YOUR TRANSPORTATION NEEDS — If indicated by your provider, make arrangements for a responsible adult to provide transportation home from the clinic and to remain with you as directed.
BE ON TIME — Arrive on time for your appointment.
CANCEL APPOINTMENTS — If you are not able to keep a scheduled appointment, you are required to cancel that appointment prior to the scheduled appointment time. We ask that you cancel with as much advanced notice prior as possible.
SHOW INSURANCE CARD — Show your insurance card, including your Health First Colorado (Medicaid) card, at each visit.
REGISTRATION INFORMATION — Please provide all necessary records as requested.
FINANCIAL SCREENING — Complete the financial screening process by bringing all insurance, income, and other requested information to the enrollment staff within 30 days of your first visit or when your insurance expires. You may be excluded from seeking care at Clinica Family Health if you do not meet with an enrollment staff member to determine program eligibility or self-pay designation.
PAY BILLS — Accept personal financial responsibility for any charges not covered by insurance. Your fees will be adjusted so that they are affordable for you. Please pay all co-pays and bills promptly.
Your Rights As Our Patient
ACCESS — Appointments are provided within a reasonable period of time. Discount programs available for individuals based on family size and income. You will not be denied health care services due to your inability to pay.
Clinica Family Health does not discriminate against any person on the basis of race, color, national origin, disability, religion, gender, gender identity, sexual orientation, or age in admission, treatment, or participation in its programs, services, activities, or employment.
Clinica will make accommodations when requested to provide care in your preferred language. You may request other reasonable accommodations related to any disability you may have. For further information about this policy and other accommodations and non-discrimination policies of Clinica, refer to our Accommodations, Nondiscrimination & Accessibility page on our website. To contact our 504 Coordinator, call 303.665.3036, ext. 1060, or send an email to 504Coordinator@clinica.org. Individuals needing TDD access can call 800.659.2656.
All patients have the right to select their pharmacy of choice, diagnostic imaging and test center(s) and preferred specialist. Patients are under no obligation to use Clinica facilities for these services.
DIGNITY — Care is provided in a manner that respects your individuality and dignity. This includes being told by your care givers what your condition is, what treatment they recommend, how they expect your condition to change, and what follow-up care is needed.
PRIVACY — All physical exams, interviews, and discussions about your health care, including appointment check-ins, will occur privately, and your health records will be handled confidentially. Clinica Family Health will handle all of your records in compliance with federal and state privacy laws (HIPAA) and will abide by the terms of this notice.
EMPLOYEE IDENTIFICATION — You have the right to know the names, professional status, and experience of the staff providing your care.
CONSENT — Consent for treatment will be requested by our medical staff before any procedure is performed. The procedure – as well as its value, risks, and other options for treatment—will be explained.
REFUSAL OF TREATMENT — You have the right to refuse any care recommended. You have the right to change your mind before undergoing a procedure for which you have already given your consent.
ACCESS TO RECORDS — You may review or receive a copy of your medical record after completing a written request. We will provide rapid access in accordance to federal law. Complaints about access to your records can be addressed to the Colorado Department of Public Health and Environment (CDPHE). Click here for the CDPHE website.
BILLS — You have a right to an explanation of all charges and discount program adjustments if you qualify for Clinica’s discount program.
FILE A COMPLAINT OR GRIEVANCE — You have the right to file a complaint if you are not satisfied with any aspect of your care. You can file a complaint using any of the following methods:
Contact Clinica Family Health at 303.650.4460 and ask to file a complaint.
You may send a complaint or grievance in writing to:
Chief of Operations
Clinica Family Health
1735 S. Public Road
Lafayette, CO 80026
You may fill out a Patient Experience Form by clicking here or asking for a paper copy in the clinic.
Contact Health and Human Services at www.HHS.gov.
CHANGE YOUR PROVIDER — You have the right to request a change of provider or clinic if another qualified provider is available. For information about how to request a change of provider or clinic, contact Clinica’s Communication Center at 303-650-4460.
USE OF YOUR HEALTH INFORMATION — Clinica Family Health is permitted to use or disclose your health information for the purposes of treatment or payment, or if the disclosure is required by law and the information released does not include any identifiable information.
Clinica Family Health does not discriminate against any person on the basis of race, color, national origin, disability, religion, gender, gender identity, sexual orientation or age in admission, treatment, or participation in its programs, services and activities, or in employment. Clinica will make accommodations to provide care in your preferred language. For information about this policy and other accommodation and non-discrimination policies of Clinica, review this website or contact our 504 Coordinator:
Phone: 303.665.3036, ext.1060
TDD: 800.659.2656
Email: 504Coordinator@clinica.org
For information on notice of nondiscrimination, click here.
For the address and phone number of the office that serves your area call: 800.421.3481.
Clinica Family Health Provides:
Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other format (large print or other formats).
Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact our Communication Center to request assistance at 303.650.4460. If you believe Clinica has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Clinica Family Health, 1735 S Public Rd, Lafayette, CO 80026. You may call 303.665.3036, ext 1060 or (TDD) 800.659.2656. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You may also file a civil rights compliant with the U.S. Department of Health and Human Services, Office of Civil Rights at www.orcportal.hhs.gov; or by mail at U.S. Department of Health and Human Services, 200 Independence Ave, SW Room 506F, HHH Building Washington, DC 20201. You can also call 800.368.1019 or (TDD) 800.537.7697.
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.
I. UNDERSTANDING YOUR HEALTH INFORMATION
Each time you visit our community health center, we create a record of your visit. This record usually contains your name and other information that may identify you, your symptoms, examination and test results, diagnoses, treatment, plan for future health care, and financial information. This record is sometimes referred to as your “medical record” or “medical chart.” This record allows:
– Doctors, nurses, and other health professionals to plan your treatment;
– Our community health center to obtain payment for services we provide to you from health plans, Medicaid, or you; and
– Our community health center to measure the quality of care provided to you.
As in the past, we are committed to keeping your health information confidential. We are required by law to maintain the privacy of your health information and to inform you of our legal duties and privacy practices with respect to your health information. We are required to abide by the terms of this notice, although we reserve the right to change the terms of this notice and will provide you with a revised version via or websites or in person should the terms change. You may request a copy of the current notice at any time. We will not use or share your health information without your written permission, except as stated in this notice.
II. HOW WE WILL USE AND GIVE OUT YOUR HEALTH INFORMATION
A. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
We will use and share your health information to provide you with health care treatments, to get paid for our services, and to help us operate our community health center. For example:
We will share your health information with health care professionals not on our staff, such as other healthcare providers and hospital staff, who help care for you. This information may be shared via fax, paper or electronic formats. We also participate in an organized health care arrangement and a health information exchange (Colorado Regional Health Information Organization or CORHIO) that enables healthcare providers to share a database containing your health information for treatment purposes and enables the delivery of better, more efficient care to you. However, you may opt out of participation in CORHIO at any time by notifying our staff, who will then provide you with the forms to do so.
We may send a bill to your health insurance plan or to you to obtain payment for services rendered.
We may use your medical record to review our performance and make sure you receive quality health care and/or to conduct training or compliance functions/activities.
B. OTHER USES AND DISCLOSURES ALLOWED OR REQUIRED BY LAW
We may use or disclose your health information for the following purposes under limited circumstances:
– To people who are involved in your care or who help pay for your care (e.g., your family, close personal friends, or any other person chosen by you) to notify them of your location, general health, and to assist you in your health care (such as to pick-up medicine or help with follow-up care);
– To government agencies that oversee our community health center (such as license and certification inspectors), and/or for specialized government functions, such as military and veteran’s activities, national security and intelligence activities, and protection of public officials;
– To government agencies that have the right to receive and collect health information (such as to control disease outbreaks). We also share health information with the Colorado Immunization Information System (CIIS), which is a confidential database housing immunization data for Coloradans. You may opt out of participation in CIIS at any time by notifying our staff, who will provide you with the forms to opt out;
– When we are ordered by a court or judge;
– To workers’ compensation programs when your health problem is from a work-related injury;
– When law enforcement requests information (such as to prevent danger or injury);
– To report information related to victims of abuse, neglect, or domestic violence or other public health-related permitted uses or disclosures;
– To coroners and funeral directors to allow them to carry out their duties upon your death, and/or for cadaveric organ, eye, or tissue donation and transplantation purposes;
– To organ donor agencies (subject to applicable laws);
– To avoid a serious threat to the health or safety of yourself or others;
– To notify or assist in notifying your family, a personal representative, another person responsible for your care, or disaster relief authorities of your location, condition, or death.
– To contact you about appointment reminders, new treatments, or medicines that may help you;
– For the purpose of research under limited circumstances;
– Through business associates or other contractual arrangements. Some services in our organization are provided through contracts and/or agreements with business associates and other healthcare organizations. Examples include physician services in the emergency department and radiology, mental health services, laboratory and diagnostic services, and other organizations who help to improve the quality of your health and healthcare experiences or assist with our back-office operations (e.g., billing, information technology, etc.). When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do. So that your health information is protected, we require business associates to safeguard your information appropriately.
We may use medical information about you to contact you in an effort to raise money for the clinic and its operations. If you are contacted in our fundraising efforts, you will have the opportunity to opt out of receiving further fundraising communications from us.
For any other purpose required or permitted by law.
C. OTHER USES AND DISCLOSURES REQUIRING YOUR WRITTEN PERMISSION
Except as stated above, we will use or give out your health information only after obtaining your written permission on an authorization form. You may revoke your authorization at any time by notifying us in writing that you wish to do so.
III. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Subject to certain legal limits, you have rights regarding the use and disclosure of your health information, including the right to:
Request limits or restrictions on uses of your health information in certain circumstances. However, we are not required to comply with requests in all cases. To request restrictions, you must make your request in writing to Clinica’s HIPAA Privacy Officer. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply.
Receive confidential communications about your health information.
Inspect and copy your health information.
Request a change or amendment to your health information.
Receive a record or accounting of how we have used or disclosed your health information.
Obtain a copy of this Notice of Privacy Practices.
You have the right to receive notice from us of a breach of your unsecured protected health information.
IV. QUESTIONS, CONCERNS, OR COMPLAINTS
If you have any questions or wish to discuss any of the information in this Notice of Privacy Practices, please contact the HIPAA Privacy Officer at 1735 S. Public Rd., Lafayette, CO, 80026. You can also call our HIPAA Privacy Officer at (303) 650-4460.
If you believe your privacy rights have been violated, you may file a complaint with our community health center or the Secretary of the Department of Health and Human Services. To file a complaint with our community health center, submit a written statement to the HIPAA Privacy Officer at 1735 S. Public Rd., Lafayette, CO, 80026. For information on how to file a formal HIPAA privacy complaint directly with the Department of Health and Human Services go to: https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html. We will not retaliate against you for filing a complaint.
