Vermont Health Information Exchange Opt-Out Form

Vermont Health Information Exchange Opt-Out Form
Vermont Health Information Exchange Opt-Out Form
Vermont Health Information Exchange Opt-Out Form

If you do not want health care professionals involved in your care to see your health information, please fill out this secure form.

Alternatively, you can contact VITL directly at 888-980-1243 or print and mail a completed form to VITL.
Alternatively, you can contact VITL directly at 888-980-1243

or print and mail a completed form to VITL.
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Primary Phone Number*
Alternate Phone Number
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (If different from Physical Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
Name(s) of hospital(s), practice(s), and other Health Care Organization(s) you have visited in the past ten years.
*

I am filling out this form on my own behalf.I am the authorized representative or legal guardian for the individual above, I am filling out this form on their behalf.
I Choose to Opt Out

Please DO NOT SHOW my health information to providers involved in my care.
You are choosing to Opt Out the identified individual

Please do not show their health information to providers involved in their care.
If you are age 12 or older, only your signature is required.

For more information on signature requirements, please contact VITL directly at 1-888-980-1243.
If the individual who is being opted out is younger than 12 years old, only your signature as the Parent or Authorized Representative of the individual is required.

For more information on signature requirements, please contact VITL directly at 1-888-980-1243.
I understand that falsifying my identity or signing on behalf of an individual in which I do not have authority is against the law and a punishable offense. For more information on signature requirements, please contact VITL directly at 1-888-980-1243.
E-Sign Below*

Clear
If the Individual is 12 years old or older, but is incapable of signing the form, then the signature of an Authorized Representative is required.

For more information on signature requirements, please contact VITL directly at 1-888-980-1243.
Signature of Legal Guardian / Authorized Representative*

Clear
Name of Legal Guardian or Authorized Representative*
Relationship to Individual*
Please verify that you are human*
Should be Empty:

Vermont Health Information Exchange Opt-Out Form

Vermont Health Information Exchange Opt-Out Form

I Choose to Opt Out

You are choosing to Opt Out the identified individual