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Patient Resources
Patient Opt-Out
Patient Opt-Out
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 HealtheParadigm, a secure, electronic Health Information Exchange (HIE)* unless you Opt-Out of HealtheParadigm.
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 HealtheParadigm
Request to Opt-In Form
.
If there are any questions in the processing of your request, a HealtheParadigm
representative will contact you using the telephone number you provided below.
*HealtheParadigm is the Health Information Exchange endorsed by the Medical Association of Georgia and operated by KaMMCO Health Solutions, Inc.
ALL FORM FIELDS BELOW ARE
REQUIRED
UNLESS NOTED "OPTIONAL."
First Name:
Middle Name:
Last Name:
DOB:
Gender:
Male
Female
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Phone Number:
Social Security Number (Optional):
Patient Email (Optional):
Physician/Facility Name (Optional):
Physician office/Facility email (Optional):
I am completing this form as a legal representative of the above noted patient.
Participants Map