Vermont Health Information Exchange Opt-Out Form

Vermont Health Information Exchange Opt-Out Form

If you do not want health care professionals involved in your care to see your health information, please fill out this secure form.

Alternatively, you can contact VITL directly at 888-980-1243 or print and mail a completed form to VITL.

First Name*

Middle Name

Last Name*

Date of Birth*

Primary Phone Number*

Please include area code.

Phone

Physical Address*

Please include street, city/town, state, and zip code.

Mailing Address

(if different from Physical Address)

Please include street, city/town, state, and zip code.

Health Care Organization(s) you have visited

Name(s) of hospital(s), practice(s), and other Health Care Organization(s) you have visited in the past ten years. This will be used to help with patient matching.

Confirmation

Would you like to receive confirmation once your opt-out request has been completed? We will use the information you provided above to send the confirmation.

Yes, please contact me by phone

Yes, please contact me by email

No need to contact me

Other

Email Address*

If other, please fill in below.*

Please select from the options below:*

I am filling out this form on my own behalf.

I am the authorized representative or legal guardian for the individual above, I am filling out this form on their behalf.

Phone Number of Authorized Signer

If different from individual's above.

Phone

Acknowledgement*

I acknowledge that by selecting the “I agree” checkbox, I am signing this document electronically. I agree and understand that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. I confirm that I am authorized to enter into this Agreement. I understand that falsifying my identity or signing on behalf of an individual in which I do not have authority is against the law and a punishable offense. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. For more information on signature requirements, please contact VITL directly at 1-888-980-1243.

I agree.

Full Name of Signer*

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