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You must read, understand and accept these stipulations in order to officially opt out. You must initial your Patient Choice Form, under Opt-Out Certification, to indicate your acceptance.

  1.  I UNDERSTAND that this request only applies to sharing my health information through WISHIN Pulse. I UNDERSTAND that when I see a health care provider for treatment, that provider may request and receive my medical information from other providers using other methods permitted by law, such as fax or mail. I am aware that health care providers who originally recorded information about me may continue to have access to this information through means other than WISHIN Pulse.
  2. I UNDERSTAND that once my opt-out request goes into effect, it will remain in effect unless I change it in writing by submitting an opt-back-in request to WISHIN via a Patient Choice Form.
  3. I have had an opportunity to ask and receive answers to all my questions about opting out of WISHIN Pulse.
  4. Any information that is disclosed before I submit this opt-out request cannot be taken back and may remain with my provider if he/she accessed such information before this request went into effect.
  5. This request, and any future request to opt back in, can take up to three business days after receipt by WISHIN to take effect.
  6. I UNDERSTAND that this WISHIN Pulse opt-out request does NOT cover or affect my opting out of any other health information exchanges, including other exchange technologies offered by WISHIN.
  7. I UNDERSTAND that if I wish to opt out of another health information exchange, I must follow the instructions of the other such exchanges to limit my participation.
  8. I UNDERSTAND and accept the risks associated with denying health care providers access to my health information through WISHIN Pulse.
  9. I UNDERSTAND that I can revoke this request at any time.