Patient Request For Exemption From Participation In Electronic Health Information Exchange (Page 3 of 3) in pdf

Patient Request For Exemption From Participation In Electronic Health Information Exchange Page 3

STANFORD HOSPITAL and CLINICS

UNIVERSITY HEALTHCARE ALLIANCE

Medical Record Number

Patient Name

CONSENT PATIENT REQUEST FOR EXEMPTION

Page 3 of 3

Addressograph or Label - Patient Name, Medical Record Number

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Section F: PATIENT REQUEST TO RESCIND EXEMPTION FROM PARTICIPATION

IN ELECTRONIC HEALTH INFORMATION EXCHANGE

By my signature dated below, I hereby notify Stanford Hospital and Clinics (SHC) and

University Healthcare Alliance (UHA), that I allow release of my SHC or UHA health

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

UHA health care providers as allowable by law.

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:

***A COPY OF THIS FORM MUST BE GIVEN TO THE PATIENT ***

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Patient Request For Exemption From Participation In Electronic Health Information Exchange Page 3