Nc Health Information Exchange Patient Opt-Out Form (Page 2 of 2) in pdf

NC Health Information Exchange Patient Opt-Out Form

Fill out and mail this form to NC Health Information Exchange at the following address:

NC Health Information Exchange

Attn: Opt Out

2300 Rexwoods Drive, Suite 390

Raleigh, NC 27607

Select one option below:

Opt-Out

 NC HIE may not share health information maintained by the caregiver(s) or health care organization(s)

listed below. I understand that all health information maintained by said caregiver(s) and/or

organization(s) will not be a part of my patient health record in NC HIE’s health information exchange

network. In cases of medical emergency, my doctor may request to view my health record to diagnose

or treat my emergency.

__________________________________________________________________________________

 NC HIE may not share any of my health information, except in instances of public health or research

purposes that are permitted by both HIPAA and NC law. In cases of medical emergency, my doctor

may request to view my health record to diagnose or treat my emergency.

Rescind Opt-Out

 I request to terminate 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 NC HIE, as

permitted or required by NC or Federal law.

All fields must be filled out in order for NC HIE to process your opt out request.

________________________________________________________________________________________

First Name

Last Name

Middle Initial

________________________________________________________________________________________

Address

________________________________________________________________________________________

City

State

Zip

________________________________________________________________________________________

Date of Birth (mo/da/yr)

Gender (M or F)

Last 4 Digits of Social Security Number

________________________________________________________________________________________

Patient Signature or Legal Representative*

Date (mo/da/yr)

*By signing as a legal representative, I am certifying that I am legally authorized to act on behalf of

the patient

Nc Health Information Exchange Patient Opt-Out Form Page 2