• CANCELLATION OF HEALTH INFORMATION EXCHANGE (HIE) OPT-OUT

  •  / /
  • By signing below, I acknowledge and agree as follows:

    1. I wish to cancel my previous decision to opt-out of the HIE in which Park Crescent Healthcare and Rehabilitation Center participates. I understand that by making this decision I am authorizing my health information to be shared by Park Crescent Healthcare and Rehabilitation Center through this HIE.

    2. I understand that the information shared by Park Crescent Healthcare and Rehabilitation Center may include information of a more sensitive nature, including but not limited to: genetic diseases or tests, substance use disorder, mental health conditions, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), and birth control and abortion (family planning).

    3. I understand that if I change my mind after opting back in, I may at any time later opt back out of the HIE in which Park Crescent Healthcare and Rehabilitation Center participates by completing and submitting a new Health Information Exchange (HIE) Opt-Out Form as indicated on the form.

    4. This cancellation of opt-out request can take up to five (5) business days after receipt by Park Crescent Healthcare and Rehabilitation Center to take effect.

  • Clear
  •  / /
  • Should be Empty: