Authorization to Disclose Protected Health Information

This document is an authorization form for members to permit Colorado Access to share their protected health information. It requires complete information, including the duration of consent and specific details on the health information to be disclosed. Members can specify the information to be shared, as well as the reasons for sharing. Importantly, it outlines the rights of members regarding cancellation of authorization and the implications of sharing their health data. The form also accommodates members represented by others, such as caregivers.