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Health Insurance Portability and Accountability Act (HIPAA)

 
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The Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is a set of complex federal rules and regulations that govern how medical institutions and their business associates treat your private health information. Your personal health information cannot be shared with ANYONE without your explicit and written permission. If you wish to share your personal health information, you may download the third-party authorization form below and complete it.

HIPAA FORM (PDF)


Below is part of the authorization with required statements by the state of Colorado:

           

Department of Health Care Policy & Financing (Colorado)

REQUIRED STATEMENTS:
I understand that the information provided based on this Authorization may be redisclosed to another party by
the authorized recipient, and that the Colorado Department of Health Care Policy and Financing has no control
over that additional disclosure and can not protect the information after it is released based on this Authorization.

I understand that I may revoke this Authorization at any time in writing to the address below. I understand that
any revocation can only apply to future disclosures or actions regarding the disclosure of my information and
cannot cancel actions take or disclosures made while the authorization was in effect.

I understand that the Colorado Department of Health Care Policy and Financing may not condition my health
care treatment or payment, or my enrollment or eligibility for benefits on my executing this Authorization.

I certify that this request has been made voluntarily and that the information given is accurate to the best of my
knowledge. A copy of this executed Authorization is as effective as the original.

Client signature:__________________________________________    Date:____________________

Parent or Legal Guardian may sign on behalf of minor child.

Legal Guardian, Power of Attorney, or equivalent may sign on behalf of adult documentation is required.

Return Completed Form by fax or mail to:
Privacy Officer
Colorado Department of Health Care Policy and Financing
1570 Grant Street, Denver, CO 80203
Fax: (303) 866-4411

 

 

 


 


 


If you need immediate assistance, please call or
email Susan Anderson
.

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phone: 716-567-4079 
email: newlifesusan@me.com