OPT-OUT OF 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-out? 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. If you have previously chosen to include your sensitive health information in a HealthInfoNet record (i.e., you have opted-in), but would now no longer like to share your information with HealthInfoNet’s participating providers, you must opt-out of this service. Completing this form will prevent your sensitive health information from being available to your providers, unless you give them one-time verbal consent or in the case of a medical emergency. For more information, you can visit our communication materials online: http://hinfonet.org/for-patients. Your choice to share or not share this information will not affect your ability to get medical care.

INSTRUCTIONS:

•  IF YOU HAVE PREVIOUSLY OPTED-IN AND DO WANT TO SHARE YOUR SENSITIVE HEALTH INFORMATION, DO NOT DO ANYTHING WITH THIS FORM.
•  IF YOU HAVE PREVIOUSLY OPTED-IN AND DO NOT WANT TO SHARE YOUR SENSITIVE HEALTH INFORMATION, PLEASE COMPLETE THE FORM BELOW.

I understand that I have previously chosen to share my sensitive health information with HealthInfoNet and that only if I check the appropriate box below will I revoke my previously authorized release of the specified type(s) of information: mental health and/or HIV information. If you decide later that you would like to include your sensitive health information in a HealthInfoNet record, you can complete an opt-in form found online: http://hinfonet.org/for-patients. Please check the box next to your choice(s):

At least one of the following check boxes is required.

Mental Health InformationI DO NOT authorize disclosure of any information related to mental health
HIV InformationI DO NOT 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-Out?

By submitting this form, I understand that my sensitive health information will not be available to providers using HealthInfoNet.

I understand that I am choosing to opt-out 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