Authorization To Opt Out Of Sharing Personal Health Information printable pdf download

Authorization To Opt Out Of Sharing Personal Health Information

Heritage

California

ACO

8510 Balboa Blvd., Suite 285, Northridge, California 91325

Date: __________________________

Authorization to Opt Out of Sharing Personal Health Information

To help you get the best possible care, Medicare shares information with Heritage California ACO about

the care their patients get. Having this information helps your doctor(s) and health care team give you

the best possible care. Your privacy is very important to us, and you control how your personal

information is used.

You can prevent Medicare from sharing your personal information with Heritage California

ACO. You can do this by:

•

Completing this form and returning it to the address on the next page; or

•

Calling 1-800 MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

A. You Can Opt Out of Information Sharing at Any Time

You have the right to opt out of having your personally identifiable medical information shared

with Heritage California ACO at any time. You can block Medicare from sharing your personal

information by completing this form or calling 1-800 MEDICARE. Your opt-out request will take effect

within 60 days.

If we get your opt-out request before _____________________, Medicare won’t share any of your

personally identifiable medical information. Otherwise, Medicare will share your personally identifiable

medical information with Heritage California ACO until your opt-out request takes effect. Once you opt

out, Medicare won’t share any of your personal medical information in the future unless you submit a

separate form letting us know you want to share this information.

At any time, you have the right to ask Heritage California ACO to explain which healthcare providers

working with Heritage California ACO will have access to your data and medical information.

I’ve read this whole section and understand my rights. I understand that by completing

this form, I’m telling Medicare not to share my personal information with Heritage

California ACO.

Signature: ________________________

Full Name: ________________________

Date: ____________________________

B. Your Information

Member ID:

________________________

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Authorization To Opt Out Of Sharing Personal Health Information