Patient Request For Exemption From Participation In Electronic Health Information Exchange Page 2

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STANFORD HOSPITAL and CLINICS
UNIVERSITY HEALTHCARE ALLIANCE
Medical Record Number
Patient Name
CONSENT PATIENT REQUEST FOR EXEMPTION
Page 2 of 3
Addressograph or Label - Patient Name, Medical Record Number
I understand that my signed request becomes effective upon receipt and processing
and will remain effective until and unless I request this to be changed. I understand
that should I wish to rescind my request for exemption from secure electronic health
information exchange to non-SHC or non-UHA health care providers, I must submit
my request in writing to Stanford Hospital & Clinics, Health Information Management
Services (HIMS) Department, 450 Broadway St. Room C14, MC5200, Redwood City,
CA 94063, or fax to (650) 498-5120.
***************************************************************************************************
Section D: INFORMATION YOU SHOULD KNOW BEFORE SIGNING
If you have questions about this form or the release of your health information, please
contact the SHC HIMS Department at 650-723-5721 before signing.
***************************************************************************************************
Section E:
By my signature dated below, I hereby request that Stanford Hospital and Clinics
(SHC) and University Healthcare Alliance (UHA), do not release my health information
via secure electronic health information exchange to non-SHC and non-UHA health
care providers as described in Section C above.
Name of patient (please print):
Name of legal representative signing this form, if applicable (please print):
Address of patient or legal representative signing this form (please print):
Phone number of patient or legal representative signing this form (please print):
If you are not the patient and you are signing this form, describe your authority to sign
on behalf of the patient and provide supporting legal documentation:
Personal Representative’s Name (print) and Relationship
Signature of patient or legal representative:
Date:

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