Health Insurance Portability and Accountability Act Privacy Forms

The following forms relate to an individual's right to the privacy of their Protected Health Information (PHI). Questions about these forms or your rights relative to Colorado's medical assistance programs can be directed to 303-866-4366.

Privacy Practices

Authorization Forms

The following forms allow us to release a client's health information to a third party.

• Personal Representative Form - EnglishandSpanish
  This form allows an individual other than the client to be able to communicate with the Department involving the client's Protected Health Information. The Personal Representative is usually a family member or someone close to the client. Court Appointed Legal Guardianship papers or a notarized Durable Medical Power of Attorney may substitute for or be used in conjunction with a Personal Representative Form. Includes both English and Spanish versions.
• Third-Party Authorization Form - EnglishandSpanish
  This form allows the disclosure of a client's Protected Health Information or claims data to a third party. Use this form to authorize the Department to release Protected Health Information to an outside entity such as a support services organization or an attorney's office. Includes both English and Spanish versions.
• Non-Attorney Authorization Form- English and Spanish
  This form allows the use and disclosure of Protected Health Information during the Appeal process. This form must be completed and returned to the Office of Administrative Courts at the address listed on the form. Includes both English and Spanish versions.

Protected Health Information

• Access to Protected Health Information - EnglishandSpanish
  T his form allows you to request a copy of your Protected Health Information that is held by the Department of Health Care Policy & Financing in what is referred to as your Designated Record Set. HCPF's Designated Record Set consists of claims information including dates of service, dates of payment, identification of provider, category of service, and payment amount.
• Request to Amend Health Information - EnglishandSpanish
  This form allows you to request that the Department of Health Care Policy & Financing amend your Protected Health Information.
• Accounting of Disclosures of Health Information - EnglishandSpanish
  This form is used to request information about the disclosure of your Protected Health Information that is held by the Department. Disclosures for the purposes of a) treatment, b) payment or c) health care operations, or when the disclosure was specifically approved by you in writing, are not included.

HIPAA Privacy Rule Complaints

• Complaints About Health Information Disclosures - EnglishandSpanish
  If you believe that the Department of Health Care Policy & Financing has violated your (or someone else's) health information privacy rights, the Department's own policies and procedures regarding HIPAA compliance, or committed another violation of the Privacy and Security Rule, you may file a complaint with the Department's Privacy Officer. Complaints must be submitted in writing to the address listed on the form.