Board of Directors

Lyons Fire Protection District Board Meetings are held at 7 p.m., on the 2nd Thursday of every month at: 251 Broadway, Lyons CO. 80540

President Paul Davidovich

Vice President Keith Spencer

Secretary Brian Roberts

Treasurer Chris Cope

Director Dave Roth

Legal Notices

Notice of Cancellation of May 2, 2023 Election

Annual Budget Information

Download Records Request Form

Resolution 2021-004 Open Records Policy

Lyons Fire Protection District Records Request Form

Step 1 of 2

NOTICE: A copy of the District's Resolution Establishing a Policy Regarding Requests for Public Records ("Policy") may be obtained from the District's administrative offices at 251 Broadway, Lyons, CO 80540, or on this website. All records requests must comply with the Policy; the Colorado Public (Open) Records Act, C.R.S. § 24-72-201, et seq.; and all other applicable laws. The District will charge fees for its responses to a records request as provided in the Policy.

Date of Request *

Person Requesting Records:

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Records Requested:

Records Requesed: Please list below the records you are requesting with as much specificity as possible, including the type of record, a date or date range, the specific subject matter, and the names of persons or locations. Please attach additional pages if more space is needed.

Protected Health Information: If any of the records you are requesting contain health information protected from disclosure under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you must submit an Authorization to Release Medical Information

List Records Below:

Delivery Method for Copies of Records: *

I wish to inspect the records at the District's administrative offices at 251 Broadway, Lyons, CO 80540, and do not want any copies of the records delivered to me.
By pick-up at the District's administrative offices at 251 Broadway, Lyons, CO 80540.
By mail
By email

For E-Mail Delivery: If any of records you are requesting contain health information protected under HIPAA, you must complete the section of the Authorization to Release Medical Information (page 2) entitled "Authorization to Transmit via Electronic Means" before ADCOM can release the records to you.

Signature *

I certify that I am the person requesting the records identified above. I agree to pay all fees and costs incurred in responding to this request pursuant to the District's Resolution Establishing a Policy Regarding Requests for Public Records before the records are released to me.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Patient Information:

Name

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Please Print Name of Patient or Patient's Representative:

I authorize Lyons Fire Protection District (“District”) to Patient or Patient's Representative
release the following records, including any Protected Health Information regarding the patient that the records contain:

Records:

Please list the records you are authorizing for release with as much specificity as possible, including the type of record, a date or date range, the specific subject matter, and the names of persons or locations. Please attach additional pages if more space is needed. You must specifically authorize the release of records relating to drug/alcohol abuse, child abuse, HIV status, genetic testing, sickle cell anemia, or mental health records. A separate authorization is required for release of psychotherapy notes.

The records listed above may be released to the following individual(s) or organization(s):

Name of Recipient:

First

Last

Organization:

Address

Address Line 1

Address Line 2

City

State

Zip Code

For the purpose of:

OPTIONAL:

Authorization to Transmit via Electronic Means:

I request that the records listed above be released to the recipient by email, and not by U.S. mail or delivery service. I understand the records will be sent through unencrypted email that is not secure and there is a risk that the records could be seen by a third party during electronic transmission, while in electronic storage, and/or upon completed delivery. The District is not responsible for unauthorized access of the Protected Health Information resulting from the emailed transmission, or for safeguarding the Protected Health Information upon delivery.

Expiration:

Unless earlier revoked, this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, on the date I become an adult according to state law.

Revocation:

I have the right to revoke this authorization in writing at any time, except to the extent that action has been taken based on this authorization.

Patient Rights:

I understand I have a right to a copy of this authorization. I have the right to inspect or copy the information to be disclosed as provided in 45 CFR 164.524. I have the right to inspect or amend my medical records as provided in 45 CFR 164.526. I have a right to an accounting of the use and disclosure of my health information to any third party as provided in 45 CFR 164.528.

Re-disclosure:

I understand that any disclosure of Protected Health Information carries with it the potential for unauthorized re- disclosure, and may no longer be protected by federal confidentiality rules.

Signature

I understand that authorization for the disclosure of these records and Protected Health Information is voluntary and I can refuse to sign this authorization. I understand that medical treatment, payment, enrollment, and eligibility for benefits cannot be, and are not, conditioned on whether I sign this authorization. Photocopies of this authorization may be used in lieu of the original.

Signature of Patient or Personal Representative:

Date:

Printed Name of Patient or Personal Representative:

Date:

Description of Personal Representative's Authority:

Date: