TL CANCELATION OF HEALTH INFORMATION EXCHANGE (HIE) OPT-OUT

CANCELLATION OF HEALTH INFORMATION EXCHANGE (HIE) OPT-OUT
Patient Name (Full Name)*

First NameLast Name
Home Address*
Date of Birth*

MonthDayYear
Date
Telephone Number*
Email Address*
example@example.com
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 Tower Lodge Care Center participates. I understand that by making this decision I am authorizing my health information to be shared by Tower Lodge Care Center through this HIE.
2. I understand that the information shared by Tower Lodge Care 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 Tower Lodge Care 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 Tower Lodge Care Center to take effect.
Signature of Resident/Patient or Resident'/Patient's Legal Representative (as applicable)*

Clear
Date*

MonthDayYear
Date
Name of Resident's/Patient's Legal Representative (Print)*
Relationship to Resident/Patient or Statement of Authority to act on Resident/Patient's Behalf (e.g., health care representative under healthcare power of attorney/proxy, legal guardian, etc*
Should be Empty:

CANCELLATION OF HEALTH INFORMATION EXCHANGE (HIE) OPT-OUT