The medical groups, hospitals, and other health care-related entities (Participants) who care for you and related parties who pay for such health care services share your health information through HIE, a secure, electronic Health Information Exchange (HIE)* unless you Opt-Out of HIE.

If you do not want your health information shared and used through the HIE, complete and submit the form below. By submitting this completed Opt-Out Form you understand and agree that:

• Your information will not be available to Participants and it may not be available in the event of an emergency.
• Participants are not required to remove any health information that was shared with them through the HIE prior to the date of this form being submitted and processed.
• It may take between 2 – 5 business days to process this Opt-Out form.
• If you want your health information shared through the HIE in the future, you must complete and submit a HIE Request to Opt-In Form.

If there are any questions in the processing of your request, a HIE representative will contact you using the telephone number you provided below.