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Form-Hcpf Access To Protected Health Information - Privacy Officer, Colorado Department Of Health Care Policy And Financing

ACCESS TO PROTECTED HEALTH INFORMATION

Mail To: Privacy Officer, Colorado Department of Health Care Policy and Financing

1570 Grant Street, Denver, CO 80203

*** Please include copy of your Medicaid ID card and Driver’s License, or equivalents ***

The Health Insurance Portability and Accountability Act of 1996 requires that we protect the privacy of your

protected health information. You have a right to request a copy of your protected health information contained

in a designated record set and held by the Department of Health Care Policy and Financing. This request must

be made in writing, and may be denied by the Department under certain circumstances. You cannot have

access to any psychotherapy notes taken by your mental health therapist or information prepared for use in a

civil, criminal or administrative legal action. The Department will act on your request within 30 days (60 days if

the information is off site), unless we provide you with notification in writing that a 30-day extension is needed.

If the Department denies your request, we must provide you with a written explanation of the basis for that

denial. In some situations, you have a right to request a review of our denial. See the Department’s Privacy

Policy and Procedures on Right to Access Protected Health Information, pursuant to 45 C.F.R. 164.524.

Client Name:

Medicaid ID number:

Date of Birth:

Address:

City, State, Zip:

Phone number:

Information Requested:

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.

If signing on behalf of another person, please provide the information below:

Name of Designated Personal Representative: _______________________________________

Relationship to client: ___________________________________________________________

ALTERNATE MAILING: If you would prefer to have your protected health information record mailed to

an alternate location, please provide additional information:

Address: _____________________________________________________________________

City, State, Zip: ________________________________________________________________

FOR INTERNAL USE ONLY

Date received:

Reviewed by:

Reviewer’s comments and actions:

HIPAA Access Form-HCPF 08/2011

Form-Hcpf Access To Protected Health Information - Privacy Officer, Colorado Department Of Health Care Policy And Financing