Patient Request For Exemption From Participation In Electronic Health Information Exchange printable pdf download

Patient Request For Exemption From Participation In Electronic Health Information Exchange

STANFORD HOSPITAL and CLINICS

UNIVERSITY HEALTHCARE ALLIANCE

Medical Record Number

Patient Name

CONSENT PATIENT REQUEST FOR EXEMPTION

Page 1 of 3

Addressograph or Label - Patient Name, Medical Record Number

PATIENT REQUEST FOR EXEMPTION FROM PARTICIPATION IN ELECTRONIC

HEALTH INFORMATION EXCHANGE

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Section A:

Patient name (last, ﬁ rst, middle):

Address:

SHC/UHA Medical Record Number (if known):

Date of Birth: ________

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Section B: SECURE ELECTRONIC HEALTH INFORMATION EXCHANGE

Secure electronic exchange of health information helps ensure better care and

coordination of care. The Stanford Hospital & Clinics (SHC) and the University

Healthcare Alliance (UHA) participate in health information exchange(s) that allow

outside providers who need information to treat you to request and receive your health

information through secure electronic health information exchange. For example,

your non-SHC or non-UHA health care providers will be able to request and receive a

summary of your allergies, medications, tests, and other clinical information which may

not otherwise be readily available to them in your non-SHC or UHA medical records.

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Section C: Request for Exemption from Participation in ELECTRONIC Health

Information Exchange

I do not wish to participate in the release of my medical information from SHC

or UHA via secure health information exchange to my non-SHC or non-UHA

health care providers for my care management and treatment. I understand that

by honoring this request, SHC and UHA will not share my health information to my

other providers via secure electronic health information exchange, except as otherwise

authorized under State and Federal patient health information privacy laws.

I understand that my request to be exempted from the secure electronic health

information exchange does not affect my non-SHC or non-UHA health care

provider’s ability to otherwise obtain my SHC or UHA health information through other

approved release of information procedures.

I understand that by signing this request, my non-SHC and non-UHA health care providers

may not receive automatic notiﬁ cation via the secure electronic health information exchange

system about my care provided by SHC or UHA for continuity of care purposes.

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Patient Request For Exemption From Participation In Electronic Health Information Exchange