Forms for Managing My Records

Accounting of Disclosures (Who has accessed my records?):

• View/Download PDF
• Adobe Sign; Complete and sign electronically

Request for Amendment of the Medical Record (A change, edit or update of medical record information that you believe is incorrect):

• View/Download PDF
• Adobe Sign; Complete and sign electronically

Request to Limit the Use or Release of Records (I do not authorize Denver Health to use/disclose to a person or entity):

• View/Download PDF
• Adobe Sign; Complete and sign electronically

Medical Durable Power of Attorney (Healthcare planning document appointing your healthcare agent in medical decision making):

• PDF English
• PDF Spanish
• PDF Amharic
• PDF Arabic
• PDF Dari
• PDF Russian
• PDF Vietnamese

Forms to request or restrict access to MyChart records:

• MyChart Adult Proxy Access Request Form ‐ PDF