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 KONZA.

ALL FORM FIELDS BELOW ARE REQUIRED UNLESS NOTED "OPTIONAL."

Name(Required)

First Middle Last

Date of Birth(Required)

Gender

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Social Security Number (Optional)

Patient Email (Optional)

Physician/Facility Name (Optional)

Physician office/Facility email (Optional)

Notice

I am completing this form as a legal representative of the above noted patient.

Name

This field is for validation purposes and should be left unchanged.