Release of Information Authorization or Revocation Form

This form allows members to authorize Colorado Access to share their health information with specified individuals or organizations. It details the types of information that may be shared, purposes for sharing, and outlines the member’s rights regarding the authorization. Members may set a specific expiration date for the authorization, and they can revoke it at any time. The document also emphasizes the confidentiality of health information and provides contact details for assistance. Properly completing this form is essential for its validity.