Details about the information accessed through HealtheConnections and the consent process:
1. How Your Information May be Used. Your electronic health information will be used only for the following healthcare
Treatment Services. Provide you with medical treatment and related services.
Insurance Eligibility Verification. Check whether you have health insurance and what it covers.
Care Management Activities. These include assisting you in obtaining appropriate medical care, improving the
quality of services provided to you, coordinating the provision of multiple health care services provided to you, or
supporting you in following a plan of medical care.
Quality Improvement Activities. Evaluate and improve the quality of medical care provided to you and all patients.
2. What Types of Information about You Are Included. If you give consent, the Provider Organization and/or Health Plan
listed may access ALL of your electronic health information available through HealtheConnections. This includes
information created before and after the date this form is signed. Your health records may include a history of illnesses or
injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you
have taken. This information may include sensitive health conditions, including but not limited to:
Alcohol or drug use problems
Birth control and abortion (family planning)
Genetic (inherited) diseases or tests
Mental health conditions
Sexually transmitted diseases
3. Where Health Information About You Comes From. Information about you comes from places that have provided you
with medical care or health insurance. These may include hospitals, physicians, pharmacies, clinical laboratories, health
insurers, the Medicaid program, and other organizations that exchange health information electronically. A complete,
current list is available from HealtheConnections. You can obtain an updated list at any time by checking
HealtheConnections website at http://healtheconnections.org/ or by calling 315.671.2241 x5.
4. Who May Access Information About You, If You Give Consent. Only doctors and other staff members of the
Organization(s) you have given consent to access who carry out activities permitted by this form as described above in
5. Public Health and Organ Procurement Organization Access. Federal, state or local public health agencies and certain
organ procurement organizations are authorized by law to access health information without a patient’s consent for certain
public health and organ transplant purposes. These entities may access your information through HealtheConnections
for these purposes without regard to whether you give consent, deny consent or do not fill out a consent form.
6. Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access to or use of
your electronic health information. If at any time you suspect that someone who should not have seen or gotten access to
information about you has done so, call the Provider Organization at: [insert Provider Organization phone]; or visit
HealtheConnections website at http://healtheconnections.org/; or call the NYS Department of Health at 518-474-
4987; or follow the complaint process of the federal Office for Civil Rights at the following link: