Cancellation of health information exchange (HIE) Opt-out

Patient first name

Patient last name

Home address

Date of Birth

Telephone Number

Email Address

By signing below, I acknowledge and agree as follows:

I wish to cancel my previous decision to opt-out of the HIE in which Wellington Estates participates. I understand that by making this decision I am authorizing my health information to be shared by Wellington Estates through this HIE.
I understand that the information shared by Wellington Estates may include information of a more sensitive nature, including but not limited to: genetic diseases or tests, substance use disorder, mental health conditions, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), and birth control and abortion (family planning).
I understand that if I change my mind after opting back in, I may at any time later opt back out of the HIE in which Wellington Estates participates by completing and submitting a new Health Information Exchange (HIE) Opt-Out Form as indicated on the form.
This cancellation of opt-out request can take up to five (5) business days after receipt by Wellington Estates to take effect.

Date

Name of Resident's/Patient's Legal Representative (Print)

Relationship to Resident/Patient or Statement of Authority to act on Resident/Patient's Behalf (e.g., health care representative under healthcare power of attorney/proxy, legal guardian, etc

Signature

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Signature of Resident/Patient or Resident’s/Patient’s Legal Date Representative (as applicable)

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Cancellation of health information exchange (HIE) Opt-out

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Contact Information