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.
- 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.
- 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.
- I have had an opportunity to ask and receive answers to all my questions about opting out of WISHIN Pulse.
- 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.
- This request, and any future request to opt back in, can take up to three business days after receipt by WISHIN to take effect.
- 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.
- 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.
- I UNDERSTAND and accept the risks associated with denying health care providers access to my health information through WISHIN Pulse.
- I UNDERSTAND that I can revoke this request at any time.