WE HEALTH INFORMATION EXCHANGE (HIE) OPT-OUT

HEALTH INFORMATION EXCHANGE (HIE) OPT-OUT
Patient Name *
(First, Middle, Last)
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 opt-out of the HIE in which Wellington Estates participates. I understand that by making this decision my health information will not be shared by Virtua through these HIE(s)s to any HIE participants outside of Virtua involved in my care, even in cases of a medical emergency.
2. I understand that opting out of the HIE does not prohibit Wellington Estates from sharing my information with others involved in my care, as permitted by law, by methods other than the HIE, such as by phone, fax, mail, secure email or other electronic communications.
3. I understand that this HIE Opt-Out Form only prohibits Wellington Estates from sharing my health information through the HIE that -Wellington Estates participates in. I understand that my non-Wellington Estates health care providers may also participate in HIEs. If I wish to opt-out of HIEs my other health care providers participate in, I am responsible for contacting each of my other health care providers for information on how to opt-out.
4. I understand that this opt-out will remain in effect unless I choose to opt back in. I may opt back in at any time by completing Wellington Estates Cancellation of Health Information Exchange (HIE) Opt-Out Form and submitting as indicated on the form.
5. This opt-out may take up to five (5) business days after receipt by Wellington Estates to take effect.
6. This opt-out does not apply to any of your health information shared by Wellington Estates through the HIEs before this opt-out takes effect.
Signature*

Clear
Signature of Resident/Patient or Resident’s/Patient’s Legal Date Representative (as applicable)
Date*

MonthDayYear
Date
Print Name*
Name of Resident/Patient’s Legal Representative (Print)
Relationship*
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: