To be completed by any individual who previously completed the OPT-OUT process and would now like to OPT-Back-In.

You can allow participating medical groups, hospitals, and other health care-related entities (participants) who care for you and pay for such services to share your health information through HIE, a secure, electronic Health Information Organization (HIE). The purpose of the HIE is to give participants access to your health information for purposes of treatment, payment, and health care operations, as well as other purposes permitted or required by law. Previously, you asked the HIE not to share and use your health information through the HIE. By completing this request, you are directing the HIE to allow your health information to be shared and used through the HIE. Your participation in the HIE is voluntary and your receipt of treatment or health plan coverage for treatment will not be conditioned on whether or not you sign this form.

By signing this Request to Opt-Back-In, you ACKNOWLEDGE, AUTHORIZE and AGREE as follows:

Your health information may be shared with, and used by:

• The Participants of the HIE that are involved in your care or payment for your care for purposes of treatment, payment, and health care operations, as well as other purposes permitted or required by law; and,
• The participants of other health information organizations with which the HIE connects with for the same purposes.

Your health information that is shared through the HIE may:

• Include health information from both before and after today’s date. It may include information related to treatment you received that is possessed by any Participant who is connected to the HIE. A list of Participants, as well as other health information organizations that the HIE connects with can be found on this website.
• Include, but not be limited to, information about your diagnoses, procedures, allergies, test results (like x-rays or laboratory), and medications that have been prescribed to you. Such information may also include Sensitive Health Information e.g., mental health information, HIV/AIDS, genetic information and test results, some alcohol and drug abuse treatment information, communicable diseases, and developmental disability treatment.

Health care providers who receive health information about you through the HIE may copy and include your health information into their own medical records when caring for you.

• It may take between 2 – 5 business days to process your Request to Opt-Back-In and make your information available for sharing through the HIE.
• You may opt-out of the HIE at any time by submitting the completed online Opt-Out Form.
• You consent, authorize, and agree that all your health information including, but not limited to, Sensitive Health Information, may be shared with, and used by, all Participants of the HIE as set forth in this Request to Opt-Back-In.