• 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.

  •  - -Pick a Date
  • 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.

  • 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. 

     

  • Clear
  • Should be Empty: