Forms

Adult History Form - English/Spanish English Adult History Form - English/Spanish En Español

Adult Patient Packet English Adult Patient Packet En Español

Child Patient Packet English Child Patient Packet En Español

Consent to Treat English Consent to Treat En Español

HIPAA & Confidential Communication Request English HIPAA & Confidential Communication Request En Español

PCHC Patient Information Form English PCHC Patient Information Form En Español

Request for Medical Records English Request for Medical Records En Español

Request of Medical Provider Transfer English Request of Medical Provider Transfer En Español

We respect your right to confidentiality. Pueblo Community Health Center will release information regarding your health care only with written permission from you. If you or an authorized representative (other than your doctor) requests a copy of your health care records, we will copy and mail records to another doctor for a fee. You will be charged reasonable copying and/or delivery fees for records released with your permission directly to you or to another party. For current rates, contact Medical Records at 719-543-8711. It will take approximately 20 working days to process a request for a copy of your health care records. Note: The copying fee is subject to change without notice.

CONTACT US

(719) 543-8711

General Inquiries: info@pueblochc.org
PCHC Medical Records: records@pueblochc.org

110 East Routt Avenue
Pueblo, CO 81004

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Patients

RESOURCES

As a Federally Qualified Health Center (FQHC), Pueblo Community Health Center is eligible for Federal Torts Claim Acts (FTCA) medical malpractice liability protection. As such, Pueblo Community Health Center is a Health Center Program grantee, under 42 U.S.C. 254b, and a deemed Pueblo Health Service employee, under 42 U.S.C. 233(g)-(n)