This form should be completed by consumers who DO NOT want to participate in HealthShare Exchange (HSX), the Health Information Exchange (HIE).

Health information exchange is the electronic sharing of health information between participating healthcare providers in a way that ensures the secure exchange of health information to provide care to patients.

By submitting this Opt Out Form, health information about you will NOT be accessible to healthcare providers and other authorized users through the HIE. HSX participants who search for information about you will receive a message informing them that you Opted Out.

This request does not prohibit your healthcare provider from otherwise disclosing your medical information based on other authorizations and applicable law, or by other methods.

You can choose to participate in the HIE again at any time by calling (855) 479-7372 or email