EFTA00313916.pdf

NYUlaneone Hearth HEALTH INFORMATION EXCHANGE, CARE EVERYWHERE AND HEALTHIX CONSENT FORM In this Consent Form. you can choose whether to allow the headh care providers listed on the NYU Langone Medica Health Information Exchange ('NYUL Health l Center HIE') website http lehealth-Ohnect.rried nvu.edu ("HIE Partici NYU health care providers who may request access pants') and non- to your medical records for purposes of current treatment (tare Everywhere Providers') to obtain access to your medical record s through a computer network operated by the NYUL HIE. In order for a Care EveryMere Provider to know that Health information may be available through the NYUL Health HIE, you must tell them that you werelare a patient of an HIE Participant and that such information may be available upon This can help collect the medical records you have request. in different places where you get heath care. and make available electronically to the providers treating you them You may also use this Consent Form to decide whether or not to allow employees. agents or members of the medical NYU Hospitals Center to see and obtain access to staff of your electronic health records through Heather. which Information Exchange. or Regional Heath Information is a Health Organization (RHIO). a not-for-profit organization recogn state of New York This can also help collect the ized by the medical records you have in different places where you get make them available electronically to the providers treatin healthcare. and g you. This consent also gives your permission for Langone Heath program in which you are a any NYU patient or member to access your records from your other providers authorized to disclose information through Hes!Utz. healthcare A complete list of current Healthix Information Source available from Healthix and can be obtained at any s is time by checking the Healthix website at gto:/r~ healthy( calling Heather at 877-695-4749. Upon request. your provid Ora or by er will print this list for you from the HeaAtha website. YOUR CHOICE WILL NOT AFFECT YOUR ABILITY TO GET MEDICAL CARE OR HEALTH INSURANCE COVE YOUR CHOICE TO GIVE OR TO DENY CONSENT MAY RAGE. NOT BE THE BASIS FOR DENIAL OF HEALTH SERVICES. The NYUL Health HIE and Healthy( share inform ation about peoples health electronically and securely to of hearth care services. This kind of sharing is called ehealt improve the quality h or health Information technology (health IT) To learn more about eheafth in New York State. read the brochure. 'etter Information Means Better Care' You can ask your health provider for it, or go to the website care Aww.ehealth4tWdrd PLEASE CAREFULLY READ THE INFORMATION ON THE FACT SHEET BEFORE MAKING YOUR DECISION. Your Consent Choices You can fill out this form now or in the future. You have the following choices Please check one box 2 below. 1. I GIVE CONSENT to ALL of the HIE Partic • Care Everywhere Providers to access ALL of my HIE and I GIVE CONSENT to ALL employees, agent ipants listed on the NYUL Health HIE website Center to access ALL of my electronic health inform and electronic heath information through the NYUL Health s and members of the medical staff of NYU Hospi ation through HEALTHIX in connection with arty of tals the permitted purposes described in the fact sheet includi ng providing me any health care services, "eluding emergency care. • 2. I DENY CONSENT to ALL of the HIE Participants listed on the NYUL Health HIE websi Care Everywhere Providers to access my electro HEALTHIX for any purpose, even en a medical emerg te and nic health information through the NYUL Health HIE or ency NOTE: UNLESS YOU CHECK THE "I DENY CONS ENT" BOX, New York State law allows the people emergency to get access to your medical records, treating you in an including records that aro available through the NYUL IF YOU DON'T MAKE A CHOICE, the records will Health HIE. not be shared except In an emergency as allowe State Law. d by New York Tf r . Pt -t -N PRINT Name of Patient ( -reff•--1 19s2 Patient Date of Birth Signature of Patient or Patient's Legal Representative Date Print Name of Legal Representative (if applicable) Relationship of Legal Representative to Patent (if applicable) EFTA00313916