Health Information Exchange Form - Physicians Health Center

Patient Name:*

DOB*

Date

What is Health Information Exchange (HIE) and why is it important?
PHC participates in the exchange of electronic health information with other health care providers through HIEs. This technology allows patients’ health information, including medical history, diagnosis, treatment, medications, and test results, to be available and viewed electronically by your doctor and medical team members. HIEs are designed to provide quick access to medical records to make treatment more effective and efficient.

How will patients’ health information be used and who can access it?
PHC participates in several HIEs. Patients’ health information will be accessible to other health care providers that participate in the HIEs that are involved in the patient’s care. Such providers will have access to patients’ health information, and it can only be used for treatment, payment and health care operations.

Is patients’ electronically shared health information kept safe and private?
Protecting patient information is an integral part of how PHC conducts business. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security and Breach Notification Rules are the main federal laws that protect your health information. States may also have laws that are more restrictive than federal law. PHC follows all state and federal privacy and security laws to protect and secure patient health information.

What are patients’ options regarding HIEs?
Patients have the right to decide whether providers can access their health information via an HIE. If patients do not want their health information shared through an HIE, they may complete the Patient HIE Opt-Out Request Form. This form is available at each PHC location. PHC will honor a patient’s request to opt-out of HIEs, except in emergencies when necessary to properly treat the patient and when otherwise required by law. It is important to note that a patient’s request to opt out of HIEs may result in healthcare providers not having access to needed information to provide appropriate care.

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Relationship to Patient (If signed by a person other than yourself, please check the relationship and provide proof of authority.)*

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Patient Fact Sheet About Health Information Exchanges