Health Information Exchange
Patient Opt-Out Form
This form is to be used by patients who do not wish to participate
in Maryland’s statewide Health Information Exchange (HIE).
A Health Information Exchange, or HIE, is a way of sharing your health information among participating doctors’ offices, hospitals, labs, radiology centers, and other health care providers through secure, electronic means. The purpose is so that each of your participating caregivers can have the benefit of the most recent information available from your other participating caregivers when taking care of you. When you opt out of participation in the HIE, doctors and nurses will not be able to search for your health information through the HIE to use while treating you. Your physician or other treating providers will still be able to select the HIE as a way to receive your lab results, radiology reports, and other data sent directly to them that they may have previously received by fax, mail, or other electronic communications. Public health reporting, in accordance with law such as the reporting of infectious diseases to public health officials, will also occur through the HIE after you decide to opt out.
For more information about opting out or rejoining the CRISP HIE,
please visit www.crisphealth.org, call 1-877-95-CRISP (27477), or email email@example.com.
Information for Patient Opting Out
Address Line 1*
Address Line 2
District of Columbia
Primary Phone Number (xxx-xxx-xxxx)*
Secondary Phone Number
Date of Birth (mm/dd/yyyy)*
Reason for Opting Out (optional)
If this form is submitted by someone other than the person named above, the person submitting the form hereby certifies that he/she is acting as (CHECK ONE):
Specify relationship to the person named above
Contact Information for Individual Completing This Form If Other Than Patient
I would like to be notified of my participation choice in the following way (choose one)