Opt-Out Form

Opt-Out Form

For electronic health information exchange. Please review the patient guide brochure before completing this form. You will be required to initial the statements below to indicate that you have read and understood each statement.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
blanks* (your initials). By submitting this opt-out form, information about me will not accessible to healthcare professionals and other authorized users (including emergency services) by use of the electronic health information exchange.
blanks* (your initials) This request does not prohibit my healthcare provider from otherwise disclosing my medical information pursuant to other authorizations and applicable laws, or by other methods, including fax.
blanks* (your initials). I may choose to participate in electronic health information exchange again at any time by submitting an opt-un form.
By signing this form, I verify that I am the person named above, or that I am legally authorized to complete and sign this form for the person named above. The information provided on this form and the preferences expressed herein are true and correct to the best of my knowledge, information, and belief.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Guardian or Representative Signature

Clear
Relationship to Patient
If legal guardian or representative, please state your relationship to the patient.
Should be Empty: