"*" indicates required fields Click here to review the Authorization for Health Information Exchange Form The Health Information Exchange (HIE) system is a secure computer system that brings your protected health information (PHI) from different healthcare locations into one nationwide electronic health record. The HIE system network provides participating practitioners access to past and present medical and behavioral health information to make better decisions and better coordinate care with your healthcare team. The HIE system takes your privacy and security very seriously. The HIE system does not store any of your health/clinical data and uses end-to-end encryption to help ensure your data is secure. Only those involved in your care can look at your information.Person Receiving Services Legal Name* First Last Date of Birth* MM slash DD slash YYYY Medical Health and Sensitive PHI Information The State of Connecticut participates in the HIE, meaning that medical health information (e.g. immunizations, medications, physical examinations, and psychiatric information, etc.) are shared with other medical providers unless a specific opt-out is received. Additionally, sensitive PHI is PHI that is “subject to heightened confidentiality requirements in compliance with all federal and state laws as amended from time-to-time (e.g. HIV, substance abuse and mental health records)”. Clients must specifically authorize disclosures of sensitive PHI.* I opt-in for Child and Family Agency of Southeastern CT, Inc. (CFA) to share information from and to the HIE. I opt-in for CFA to only receive documents from the HIE. I opt-in for CFA to only send documents from the HIE. I want to opt-out of any medical information and sensitive PHI being sent to other health care providers. By signing below, I understand and acknowledge the following: My sensitive health information will be available to providers using The HIE system. I understand that refusal to sign this authorization form will not affect my right to obtain present and future services. I also understand that I may opt-out of HIE at any time by notifying CFA of the named recipient in writing. Electronic signature of person authorizing health information exchange* Today's Date* MM slash DD slash YYYY Relationship to Person Receiving Services* Self Parent Legal Guardian Define:*
