Adult Health History (Page 9 of 9) in pdf

Patient Consent Form for Electronic Exchange

of Individual Health Information

HealtHIE Nevada is a non-profit organization dedicated to connecting the healthcare community to share information

electronically and securely to improve the quality of healthcare services. To learn more about the Health Information

Exchange (HIE), read the Patient Information brochure. You can ask the doctor that gave you this form for it, or go to

the website

Details about patient information in HealtHIE Nevada and the consent process:

1. How your information will be used and who can access it: When you provide consent, only HealtHIE

Nevada participants (such as doctors, hospitals, laboratories, radiology centers, and pharmacies), will have

access to your health information. It can only be used to:

•

Provide you with medical treatment and related services.

•

Evaluate and improve the quality of medical care provided to all patients, using de-identified health

information.

2. Types of information included and where it comes from: The information about you comes from

organizations that have provided you with medical care, and are HealtHIE Nevada participants. These may

include hospitals, physicians, pharmacies, clinical laboratories, and other healthcare organizations. Your health

records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results

(like X-rays or blood tests), and lists of medications your doctor has prescribed. This may include information

created before the date of this Consent Form. This information may relate to sensitive health conditions,

including but not limited to:

• Alcohol or drug use problems

• HIV/AIDS

• Birth control and abortion (family planning)

• Genetic (inherited) diseases or tests • Mental health conditions • Sexually transmitted diseases

3. Improper Access or Disclosure of your Information: Electronic information about you may be disclosed by a

participating doctor to others only to the extent permitted by Nevada State Law. If at any time you suspect that

someone who should not have seen or received information about you has done so, you should notify your

doctor.

4. Effective Period: Your consent becomes effective upon signing this form and will remain in effect until the day

you revoke it or HealtHIE Nevada ceases to conduct business.

5. Revoking your consent: At any time, you may revoke your consent by signing a new consent form and giving it

to your doctor. These forms are available at your doctor’s office, or by calling 855-484-3443. Changes to your

consent status may take 24-48 hours to become active in the system.

Note: Organizations that access your health information through HealtHIE Nevada while your consent is in effect

may copy or include your information into their own medical records. Even if you later decide to withdraw your

consent, they are not required to return it or remove it from their records.

6. How your information is protected: Federal and State laws and regulations protect your medical information.

HIPAA, the Healthcare Insurance Portability and Accountability Act of 1996, is the federal law that protects your

medical records and limits who can look at and receive your health information, including electronic health

information. HIPAA’s protections were further strengthened by another federal law, the HITECH Act of 2009,

which may impose severe financial fines on anyone who violates your medical privacy rights. All health

information made available on the HIE, including your medical information, is encrypted to federal standards and

is accessible only as allowed by Nevada State law (NRS 439.590). In addition, your doctor must provide you with

a Notice of Privacy Practices, which describes how he or she uses and protects your medical information.

Copy of Form: You are entitled to receive a copy of this Consent Form after you sign it.

Adult Health History Page 9

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