A health information exchange (HIE) allows health care providers, including facilities owned by Southwell Ambulatory, Inc. (SWA Facilities), to share and receive information about patients, which assists in the coordination of patient care. SWA Facilities participate in HIEs which allows patient health information to be shared electronically with other providers, health plans and health care clearinghouses.

Through its participation in HIEs, SWA Facilities make patient information available electronically to other HIE participants (providers, health plans and health care clearinghouses) and receive information from other HIE participants.

Participation is Voluntary. Participation in HIEs is voluntary and will not affect patient’s ability to receive medical care.

By choosing to opt-out of participating in the HIE, I hereby acknowledge and agree as follows:

1. My health information will still be sent to the HIE, but it will not be viewable by other HIE participants.
2. The HIE will block other HIE participants from electronically accessing my health information, even for emergency treatment.
3. Access to my health information will be blocked within five (5) business days after the SWA Facility receives this opt-out notice.
4. Any information that is shared before SWA Facilities receive this HIE Opt-Out Form may remain with providers who accessed the information before this opt-out was received.
5. I understand that I may revoke this opt-out request at any time and can do so by completing and submitting an HIE Opt-In Form.