Patient Opt-Out

The medical groups, hospitals, and other healthcare-related entities (Participants) who care for you and related parties who pay for such healthcare services share your health information through Carolina eHealth Network, a secure, electronic Health Information Exchange (HIE)* unless you Opt-Out of Carolina eHealth Network.

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 Carolina eHealth Network Request to Opt-In Form.

If there are any questions in the processing of your request, a Carolina eHealth Network representative will contact you using the telephone number you provided below.

*Carolina eHealth Network is the Health Information Exchange endorsed by the South Carolina Medical Association and operated by KONZA National Network.

Patient Opt-Out

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.

Participants Map