The Colorado Department of Public Health and Environment’s Mobile Public Health Clinic Program values the privacy of patients and is committed to ensuring confidentiality.
To learn about how the program uses private medical information, read our Notice of Privacy Practices. This notice is available in Spanish, Arabic, Simplified Chinese, Korean, Russian, Somali, and Vietnamese.
Under the the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), patients have the right to determine how their protected health information is used. Use the forms below to submit requests concerning your protected health information.
Privacy Complaint Form
If you believe that the Mobile Public Health Clinic Program violated your (or someone else’s) health information privacy rights or committed another violation of the HIPAA Privacy Rule, use this online form to file a complaint with the CDPHE Privacy Officer.
Request a Copy of Protected Health Information
Use this online form to request a copy of the protected health information in your personal health record.
Request to Amend Protected Health Information
Use this online form to request a change to your vaccine record or other health information.
Patient Authorization Form
Use this downloadable form to authorize the release of your protected health information to a person or facility.
Request to Restrict Disclosure of Protected Health Information
Use this online form to request that the Mobile Public Health Clinic Program not disclose your protected health information to others, including other health care providers and family members.
Request for Alternate Communication Means or Location for Protected Health Information
Use this online form to specify how and where you would like to receive communications of protected health information.
Request for Accounting of Disclosures of Protected Health Information
The Mobile Public Health Clinic Program may disclose your protected health information as required by law. Use this online form to request the Accounting of Disclosures of your protected health information.