HIPPA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

NOTICE OF PRIVACY PRACTICES:

We are committed to protecting health information about you. All information that identifies you will be kept private, and disclosed only when you authorize disclosure, except when disclosure is required to provide treatment, coordinate your care with other treating providers, perform health care operations of this facility, or receive payment for your care. You will be treated over teleconferencing using the platform Zoom, which is HIPPA secure and end to end encrypted.

You have the right to inspect and copy health information that may be used to make decisions about your care. A request must be submitted in writing on the form we have available. We may charge a fee for copies of any records requested.

You have the right to amend health information if you feel entries are incorrect or incomplete. A request must be made in writing on the form we have available.

You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described. A request must be made in writing on the form we have available.

Per the Colorado Medical Assistance Act in regards to Telehealth:

(a) That the patient retains the option to refuse the delivery of the services via telemedicine at any time without affecting the patient's right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled;
(b) That all applicable confidentiality protections shall apply to the services; and
(c) That the patient shall have access to all medical information resulting from the telemedicine services as provided by applicable law for patient access to his or her medical records.


You have the right to request restrictions on disclosures, request confidential communications in the way that we contact you, and file a complaint, submit the complaint in writing on the form we have available. You will not be penalized in any way for filing a complaint, or making any of the requests listed above.  You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services at: 200 Independence Avenue S.W., Washington, DC, 20201.

A copy of the entire Notice of Privacy Practices, which contains more detail regarding the above information, is available.

I have been provided with the information regarding privacy practices, understand the practices, and understand that I may make a verbal request to receive a detailed copy of the Privacy Notice at any time. 

By completing and submitting the form below, I understand and agree to the above terms.

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Today's Date