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The medical groups, hospitals, and other health care-related entities (Participants) who care for you and related parties who pay for such health care services share your health information through a secure, electronic Health Information Exchange (HIE)* unless you Opt-Out.

If you do not want your health information shared and used through the HIE, complete and submit the form below. By submitting this completed Opt-Out Form you understand and agree that:

  • Your information will not be available to Participants and it may not be available in the event of an emergency. 

  • Participants are not required to remove any health information that was shared with them through the HIE prior to the date of this form being submitted and processed.

  • It may take between 2 - 5 business days to process this Opt-Out form.

  • If you want your health information shared through the HIE in the future, you must complete and submit a Request to Opt-In Form.

If there are any questions in the processing of your request, a representative will contact you using the telephone number you provided below.


Thanks for your submission

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