CRISP Opt-Out

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, care coordinators, labs, radiology centers, and other health care providers through secure, electronic means. The purpose is so that each of your participating healthcare providers can have the benefit of the most recent information available from your other participating providers 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.

Please be advised that opting out does not preclude any participating organization that has received or accessed personal health information via the HIE prior to such opt-out, and incorporated such personal health information into its records, from retaining such information in its records. Additionally, in accordance with the law, Public health reporting, such as the reporting of infectious diseases to public health officials, will still occur through the HIE after you decide to opt out. Controlled Dangerous Substances (CDS) information, as part of the Maryland Prescription Drug Monitoring Program, will continue to be available through the HIE to licensed providers.

If you choose to opt out of research only, your information will be available to your treating providers, but will be excluded from any data sets created for researchers.

This opt-out form only needs to be completed once to opt out of the HIE; it is not necessary to complete for each provider. If you do not live in the District of Columbia or Maryland, but still receive care in the region, you should complete this form to opt out. If you wish to reverse your decision you may opt back in at any time by calling CRISP at 1.877.952.7477. For more information about opting out or rejoining the CRISP HIE, please visit www.crisphealth.org, call 1-877-95-CRISP (27477), or email hie@crisphealth.org.

You have several options for sending this form to CRISP:

1.Fill out an electronic version of this form by visiting the CRISP website at http://www.crisphealth.org (preferred)

2.Fill out this form and fax your completed form to 443.817.9587

3.Fill out this form and email your completed form to hie@crisphealth.org

4.Fill out this form and mail it to: CRISP, 7160 Columbia Gateway Drive, Suite 100, Columbia, MD 21046

5.Call 1.877.95.CRISP(27477)

If you wish to reverse your decision, you may opt back in at any time by calling CRISP at 1.877.952.7477.