OPT-IN TO SHARING SENSITIVE
HEALTH INFORMATION WITH HEALTHINFONET

 

What is HealthInfoNet? HealthInfoNet is a secure computer system that brings your health information from different healthcare locations into one statewide electronic health record. Your providers use this information to make better decisions about your care. It can also help them prevent mistakes, especially in an emergency. Your health record includes information about your medicines, allergies, test results, and more.

Are my records private and secure? HealthInfoNet encrypts all information and uses secure computer connections to receive and share your health information. Only those involved in your care can look at your information. To learn more about who has looked at your HealthInfoNet record and when they looked at it, you can visit http://hinfonet.org/for-patients. Note that no system is ever completely secure, but HealthInfoNet makes every effort to keep your records safe.

What does it mean to opt-in? Maine has separate rules about mental health/HIV information sharing. This sensitive information is kept private unless you choose to share it in your HealthInfoNet record. You can authorize any provider to see your sensitive information in your HealthInfoNet record at any time via one-time verbal consent. And in the case of a medical emergency, your providers will have access to it. However, completing this form will also allow your sensitive health information to be shared within your HealthInfoNet record and available to your providers for more than just one time and for more than just medical emergency. Your choice to share or not share this information will not affect your ability to get medical care.

INSTRUCTIONS:

•  IF YOU DO NOT WANT TO SHARE YOUR SENSITIVE HEALTH INFORMATION, DO NOT DO ANYTHING WITH THIS FORM.
•  IF YOU DO WANT TO SHARE YOUR SENSITIVE HEALTH INFORMATION, PLEASE COMPLETE THE FORM BELOW.

I understand that the information to be released may contain sensitive information, and that only if I check the appropriate box below will I authorize release of the specified type(s) of information: mental health and/or HIV information. Please check the box next to your choice(s):

At least one of the following check boxes is required.

Mental Health InformationI DO authorize disclosure of any information related to mental health
HIV InformationI DO authorize disclosure of any information related to HIV

* Required Fields

First Name *Middle Name
Last Name *Address *
City *State *
ZIP Code *Date of Birth *
Sex *Male Female XPhone *
E-mail *SSN
Why Are You Choosing to Opt-In?

By submitting this form, I understand that my sensitive health information will be available to providers using HealthInfoNet.

I understand that I am choosing to opt-in to sharing sensitive health information with HealthInfoNet

  


HealthInfoNet - 60 Pineland Drive, Auburn Hall, Suite 305, New Gloucester, ME 04260
customercare@hinfonet.org | www.hinfonet.org | phone 207-541-9520 or 866-592-4352