"*" indicates required fields

Authorization for Health Information Exchange (HIE)

The HIE system is a secure computer system that brings your protected health information 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 across your care teams.

  • 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 when sending data. Only those involved in your care can look at your information.

Client's Name*
(Client receiving services)
(Client receiving services date of birth)
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Client's Address*
The State of Connecticut participates in the Health Information Exchange, meaning that medical health information (e.g. immunizations, medications, physical examinations, etc.) are shared with other medical providers unless a specific opt-out is received.
Do you want to opt-out of any medical information being sent to other health care providers?*
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).”
Patients must specifically authorize disclosures of sensitive PHI.
Do you want to opt-out of sensitive PHI (e.g. HIV, substance abuse, and mental health records) being sent to other 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 by notifying Child and Family Agency of the named recipient in writing.

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