Health Records - Privacy Forms
Other Forms Related to Your Health Information
Privacy Complaint
If you believe that any of your HIPAA privacy rights have been violated, please complete and submit the “Privacy Complaint” form. The completed form will be sent to the WellPower advocate and WellPower’s Privacy and Security Officer for review.
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Cancelling an Authorization to Release Protected Health Information
In order to cancel any active Authorizations to Release Confidential and Protected Health Information legal forms that you signed with WellPower, you must first complete and submit the “Request to Revoke Authorization to Release Protected Health Information” form, which will be reviewed by the Health Information Systems Management team. Please be specific about which authorization forms you wish to cancel. Please note that:
- You may only revoke an authorization you made for yourself, your minor child, or if you are legally authorized to do so.
- You may only revoke authorizations that are on file with WellPower.
- This revocation will not affect any action WellPower took in reliance on the initial authorization prior to receiving this notice.
- The revocation will take 2 to 3 business days from the day it has been received for it to come into effect and be reflected in your health record.
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Request a correction or change to your health record
If you believe there is an error or misrepresentation of information in your health record, please complete and submit the “Request to Amend Health Record” form, which will be reviewed by the HISM Manager, your clinical care team, and the WellPower Privacy & Security Officer. Please note that your request will be considered but may not be granted, and will become a permanent part of your health record. You will be notified of the decision in writing.
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Request information about where your health information has been shared (outside of WellPower)
If you would like information about where your health information has been shared outside of WellPower, please complete and submit the “Request for an Accounting of Disclosures” form, which will be reviewed by the HISM Manager and WellPower Privacy & Security Officer. Please note that:
- You may request disclosures as far back as six years
- The accounting is not required to include:
- Disclosures to carry out treatment, payment, or healthcare operations
- Disclosures to you or your legal guardian
- Disclosures to friend and family involved in your care or for certain notification purposes
- Disclosures made to a correctional institution or law enforcement official having custody of you
- Disclosures pursuant to HIPAA compliant authorization
- Disclosures for national security intelligence purposes
- Disclosures that are made as part of a Limited Data Set
- Disclosure that are incidental to an otherwise permissible use or disclosure of your PHI
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Request to specify the how and where WellPower communicates with you about your care
If you would like to request that WellPower staff communicate with you through a specific way &/or to a specific place, please complete and submit the “Request to Receive Confidential Communications Through an Alternative Means &/or Location” form, which will be reviewed by the HISM Manager, your care team, and the WellPower Privacy & Security Officer. Please note that WellPower is only required to grant reasonable requests, and that in the case of emergencies or in the event that an alternative location is no longer available, it may not be reasonable to accommodate your communication request.
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Request to limit to whom and with whom your protected health information is shared
If you would like to request that WellPower staff share or not share your protected health information with other people and/or organizations outside of WellPower, please complete and submit the “Request for Privacy Restrictions to Use or Disclose Protected Health Information” form, which will be reviewed by the HISM Manager, your clinical care team, and the WellPower Privacy & Security Officer. Please note that:
- If WellPower receives or obtains a signed, HIPAA compliant authorization or other release of information for your protected health information, WellPower will honor the authorization or release, regardless of any restriction agreement.
- These restrictions do not apply to:
- disclosure required by law
- information compiled for use in a civil/criminal/administrative action
- disclosures to a person in services or their personal representative
- disclosures related to crimes on a WellPower property &/or against staff
- disclosures to a health plan for payment purposes
- disclosures required for healthcare operations
- disclosures to other healthcare providers related to a medical &/or psychiatric emergency
- disclosures necessary to avert a serious threat or safety in emergencies
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Contact Us
Health Information Systems Management
Address: 4141 East Dickenson Place, Office #170, Denver, Colorado 80222
Main: (303) 504-6510
Fax: (303) 504-6504
Email: HISM@wellpower.org
Hours: Monday to Friday, 8:00 am to 4:30 pm. We are closed on all major holidays. Please see wellpower.org/closures for up-to-date holiday closure information.