OPT-OUT OF SHARING GENERAL MEDICAL
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? If you do not want your health information included in a HealthInfoNet record, completing this form will prevent it from being shared with HealthInfoNet’s participating providers. Your choice to opt-out (i.e., to not share your information) will not affect your ability to get medical care. If you decide later that you would like to include your health information in a HealthInfoNet record, you can complete an opt-back-in (i.e., opt-out revoke) form found online here: http://hinfonet.org/for-patients

INSTRUCTIONS:

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

If you would like to opt-out of sharing your general medical information with HealthInfoNet, please complete ALL sections of the following form.

* 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 health information will not be available to providers using HealthInfoNet, even in an emergency.

I understand that I am choosing to opt-out of sharing 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