HIPAA Privacy Forms
Table of Contents
Privacy Forms
The following forms related to an individual's right to the privacy of their Protected Health Information 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 or privacy@hcpf.state.co.us.
Access to Protected Health Information
This form allows you to request a copy of your protected health information that is held by the Department of Health Care Policy and Financing.
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 its disclosure was specifically approved by you in writing are not included.
This form allows you to give your permission to the Colorado Department of Health Care Policy and Financing and to the Office of Administrative Courts to share your protected health information with a non-attorney representative, during a Medicaid appeal process.
Complaints About Health Information Disclosures
This form allows you to present a complaint, in writing, about situations in which you believe the Department of Health Care Policy and Financing, or other organizations that work for the Department, have not met our responsibility to safeguard your protected health information.
Designation of Personal Representative
This form allows you to designate one or more persons (usually a family member) to act as your representative and to have access to your protected health information.
This form allows you to grant the Department of Health Care Policy and Financing permission to share specific protected health information with specified individuals or organizations.
Request to Amend Health Information
This form allows you to request the Department of Health Care Policy and Financing to amend your protected health information.