Health Information Exchange (Hie) Patient Opt-Out Form Page 2

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Health Information Exchange (HIE)
Patient Opt-Out Form
Patient Identification (Internal Use)
O pt-Out – UCSDHS may not share my health information through the UCSDHS HIE.*
*Please note that UCSDHS HIE is subject to HIPAA and California laws pertaining to the disclosure
of certain health information, such as reporting public health threats. In cases of medical emergency,
a doctor may request to view health information to diagnose or treat a patient.
C ancel (Rescind) Opt-Out
I request to cancel my previous decision to opt-out. By completing and signing this form, I am
allowing my health information to be accessible to my health care providers through UCSDHS HIE,
as permitted or required by UCSDHS or Federal / State law.
All fields must be filled out in order for UCSDHS Health Information Services to process your
opt-out request.
__________________________________
______
__________________________________
First Name
M. Initial
Last Name
________________________________________________________________________________
Street Address
__________________________________
_____
______________
City
State
Zip
_____ / _____ / _____
Gender:
Male
Female
Last 4 Digits of Social Security Number: _____________
Date of Birth (mo/da/yr)
__________________________________________
_____________
___________ AM / PM
Patient Signature or Legal Representative*
Date
Time
*By signing as a legal representative, I am certifying that I am legally authorized to act on behalf of
the patient
Mail the completed and signed form to:
UC San Diego Health System - Health Information Services
200 West Arbor Drive, M/C 8825
San Diego, CA 92103-8825
Please allow 2 business days for processing the form. You may also opt-out electronically via
MyUCSDChart at
For questions: Call UCSDHS - Health Information Services at telephone 619-543-5707 during
business hours (Monday to Friday, 9:00AM – 4:00PM PST).
D3630 (4-15) Page 2 of 2

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