Adult Health History (Page 8 of 9) in pdf

For Internal Use Only: MRN________________

Patient Consent Form for Electronic Exchange of Individual Health Information

Please read through the consent form and provide the following information: (Please Print)

PATIENT NAME_________________________________________________________________________________

Last

First

Middle

PREVIOUS NAME(S)_____________________________________________________

GENDER: M____ F____

STREET ADDRESS /

P.O. BOX_____________________________________________________________________

CITY___________________________________________ STATE________________ ZIP CODE_______________

PHONE NUMBER ____________________________ EMAIL____________________________________________

DATE OF BIRTH __________(MM)__________(DD)__________(YYYY)

Nevada Medicaid Patients Please Read: Nevada law mandates that “a person who is a recipient of Medicaid

or insurance pursuant to the Children’s Health Insurance Program may not opt out of having his or her individually

identifiable health information disclosed electronically” (NRS 439.539). When a patient is no longer a Medicaid

recipient, it is the patient’s responsibility to change their consent choice, if they choose to do so. Please sign below to

indicate your acknowledgement.

Consent Choices: (CHECK ONE) Nevada Medicaid Patients are exempt from making a selection.

Your choice to give or to deny consent may not be the basis for denial of health services.

I CONSENT for all HIE participants to access ALL of my electronic health information (including sensitive

information) in connection with providing me any health care services, including emergency care.

I CONSENT ONLY IN CASE OF AN EMERGENCY for all HIE participants to access ALL of my electronic

health information (including sensitive information) ONLY in the event of a medical emergency.

I DO NOT CONSENT for any HIE participants to access ANY of my electronic health information EVEN in

the event of a medical emergency.

Signature of patient or authorized representative

Date

Time

If I sign this form as the Patient’s Authorized Representative, I understand that all references in this form to “I”, “me” or

“my” refer to the Patient.

Name of Authorized Representative (Printed)

Relationship

Date

Time

Address of authorized representative signing this form (please print):

Phone number of authorized representative

FOR INTERNAL USE ONLY

Name of Organization:_____________________________________ Name of Witness:___________________________________

As a witness to this Consent, I attest that the above signer is personally known to me or has established his/her identity with me by

satisfactory photo ID, insurance card, or other evidence of identity customarily relied upon in health care.

Adult Health History Page 8