HIPAA Privacy Forms
The following forms relate to an individual's right to the privacy of their Protected Health Information. These forms are currently available on-line for your use. Questions about these forms or your rights relative to the CO Medicaid program can be directed to 303-866-4366.
The Department's Notice of Privacy Practices can be found at CO Medicaid Program Notice of Privacy Practices.
The following forms allow the Department to release a client's health information to a third party.
Personal Representative Form: 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.
Third Party Authorization Form: 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.
Authorization Form for the Appeal Process: 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.
Access to Protected Health Information This form allows you to request a copy of your Protected Health Iinformation that is held by the Department of Health Care Policy and 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: This form allows you to request that the Department of Health Care Policy and Financing amends your Protected Health Information.
Accounting of Disclosures of Health Information: 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.
Complaints About Health Information Disclosures: If you believe that the Department of Health Care Policy and 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.