HIE OPT OUT FORM

HIE OPT OUT FORM
This is the "Opt Out Form" described in the Notice of Health Information Practices your healthcare provider gave to you. If you opt out, your healthcare providers will not be able to access your health information through the HIE, even in an emergency. If you are filling out this form for another person, the references to "you," "I" and "my" in this form refer to that other person.

If you do not want your health information shared through Health Current, fill in your name, date of birth and choose either Option 1 or 2. Sign the form and Teri's Health Services will save the form to your chart.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select best option for you:*

Block All Health Information: I do not want any of my health information shared through Health Current.Block Some Health Information: I do not want health information that comes from the healthcare provider listed below shared through Health Current. I understand that if this healthcare provider works for an organization (like a hospital or a medical group), all of my information from that hospital or medical group mayIf you select Option 2, provide the full name, address and phone number of the healthcare provider you wish to block from sharing your health information through the HIE. If you want to block more than one healthcare provider, complete and return this form for each healthcare provider.
Healthcare Provider (First and Last Name); or entity not sharing with*
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Phone
Please enter a valid phone number.
Patient Name*

First NameLast Name
Signature*

Clear
Today's Date*

MonthDayYear
Date
Guardian Name (if applicable)

First NameLast Name
Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: