"Options Counseling Authorization for Release of Information" - Colorado

Options Counseling Authorization for Release of Information is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

  • Released on April 1, 2022;
  • The latest edition currently provided by the Colorado Department of Health Care Policy and Financing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Health Care Policy and Financing.

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Options Counseling Authorization for Release of Information
Client Information
Name:
Date of Birth:
Address:
Options Counseling Agency:
I, the undersigned, hereby authorize the Options Counseling Agency to release and/or obtain verbal, electronic or written information
regarding the above named individual with the following service providers and agencies for the purpose of making referrals for services
and coordination in support of a transition to the community.
Information to
Information to
Contact Info
Provider
Name
Purpose
(phone or email)
be obtained
be disclosed
Nursing Facility
Transition
Coordination
Agency
Transition
Coordination
Agency
Improve health care equity, access and outcomes for the people we serve while saving
Coloradans money on health care and driving value for Colorado.
hcpf.colorado.gov
Options Counseling Authorization for Release of Information
Client Information
Name:
Date of Birth:
Address:
Options Counseling Agency:
I, the undersigned, hereby authorize the Options Counseling Agency to release and/or obtain verbal, electronic or written information
regarding the above named individual with the following service providers and agencies for the purpose of making referrals for services
and coordination in support of a transition to the community.
Information to
Information to
Contact Info
Provider
Name
Purpose
(phone or email)
be obtained
be disclosed
Nursing Facility
Transition
Coordination
Agency
Transition
Coordination
Agency
Improve health care equity, access and outcomes for the people we serve while saving
Coloradans money on health care and driving value for Colorado.
hcpf.colorado.gov
Information to
Information to
Contact Info
Provider
Name
Purpose
(phone or email)
be obtained
be disclosed
Transition
Coordination
Agency
Case
Management
Agency
Case
Management
Agency
Case
Management
Agency
Improve health care equity, access and outcomes for the people we serve while saving
Coloradans money on health care and driving value for Colorado.
hcpf.colorado.gov
I understand that the Options Counseling Agency cannot guarantee that the recipient will not disclose my health information to a
1.
third party. The recipient may not be subject to federal laws governing privacy of health information. I also understand that I
may review the disclosed information. The Options Counseling Agency will not release information to any third party without
written approval unless so ordered by subpoena or court order.
I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain
2.
Community Transition Services.
I understand that I may revoke this Authorization in writing at any time, except that the revocation will not have effect on any
3.
action taken by the Options Counseling Agency in reliance of this Authorization before written notice is received. I further
understand that I must provide any notice of revocation in writing to the Options Counseling Agency.
In addition to what is being considered, I would like my Options Counselor to obtain information about the following:
4.
This release is in effect one year from this signature date or you may insert a different date:
Signature of Client or Legal Guardian:
Date:
Revised April 2022
Improve health care equity, access and outcomes for the people we serve while saving
Coloradans money on health care and driving value for Colorado.
hcpf.colorado.gov
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