Opt Out / Opt In Form

The Koble-MN Health Information Exchange (HIE) utilizes a secure system that allows your health care provider to view essential health information such as medications, allergies, test results, health problems, and treatments to help them make better decisions about your care. Information is encrypted and located on a secure network.

Only Authorized Users that have your written consent may access your information. Your provider and Koble-MN maintain records of who accessed your information.

Participation is voluntary. You may choose to opt-out of participation or change a prior election by completing and signing this form and returning it to your health care provider or by sending it to the following address.

Koble-MN
400 S 4th St. Suite 410 #46667
Minneapolis, MN 55415-1419

It may take up to five (5) business days to process this request.

Your decision to opt-out of participation will not affect the sharing of your health information between your health care providers and health insurers via other methods, such as fax, mail, etc.

Participation is not a condition to receiving care. However, if you opt-out of participation, your health information cannot be searched for through Koble-MN HIE by a health care provider except as required by law. This may or may not limit the information available to your health care provider that could affect treatment options and health care decisions.

If you’ve opted out of participation, a treating health care provider may still be able to select an HIE as a way to receive your lab results, radiology reports, and other data that may have previously been sent via fax, mail or other electronic communications.

Your decision to opt-out of participation in Koble-MN will not prevent a health care provider from disclosing your Protected Health Information to the extent required by law and the use or disclosure complies with and is limited to the relevant requirements of those laws (for example, immunization records of minors and required public health reporting). However, any reported information required by law will not be available to other health care providers except as permitted by law.

To maintain a record of your choice to opt-out of participation in the HIE, your name, and limited identifying information will be kept in the record locator service.

Any health information provided prior to opting out of participation will only be available to your health care provider.

Please select one of the following options: *

I do not want to participate in the Koble-MN HIE Record Locator Service, even in the case of an emergency. I want to fully participate in the Koble-MN HIE and am revoking my prior opt-out choice.

Client's Legal Name *

First Name Middle Name Last Name

Address *

Street Address

Street Address Line 2

City State

Zip Code Country

Date of Birth *

Phone Number *

Area Code Phone Number

Email

Maiden/Previous Name

Last 4 digits of SSN *

Please indicate your relationship *

Self Parent Legal Guardian Conservator Health Care Agent / Health Care Power of Attorney

Parent Name *

First Name Last Name

Name of Legal Guardian *

First Name Last Name

Name of Conservator Health Care Agent / Health Care Power of Attorney *

First Name Last Name

My signature indicates that I am legally authorized to sign on behalf of the client.

My signature indicates that I am legally authorized to sign.

Signature *

Clear

Date *