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REVOCATION OF PRIOR HEALTH INFORMATION EXCHANGE (HIE) OPT-OUT Name:Date of Birth://Street Address: City:State:Phone:email:Zip:I hereby acknowledge and agree as follows: 1. I WISH TO REVOKE (change)

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How to fill out revocation of hie opt-out

01

Download the revocation of hie opt-out form from the relevant healthcare organization's website

02

Fill in your personal details such as name, address, date of birth

03

Sign and date the form to indicate your decision to revoke the opt-out of health information exchange

04

Submit the completed form to the appropriate department or individual at the healthcare organization

Who needs revocation of hie opt-out?

01

Individuals who have previously opted out of health information exchange (HIE) but have changed their mind and now wish to participate

02

Patients who have concerns about sharing their health information across different healthcare providers and want to revoke their previous decision

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What is revocation of hie opt-out?

Revocation of hie opt-out is the process of reversing a previous decision to opt-out of sharing health information exchange (HIE) data.

Who is required to file revocation of hie opt-out?

Individuals who previously opted out of sharing their health information through HIE are required to file revocation if they want to change their decision.

How to fill out revocation of hie opt-out?

To fill out revocation of hie opt-out, individuals need to complete the necessary form provided by the HIE organization or healthcare provider, and submit it according to the instructions provided.

What is the purpose of revocation of hie opt-out?

The purpose of revocation of hie opt-out is to allow individuals to change their decision and consent to share their health information through HIE.

What information must be reported on revocation of hie opt-out?

The revocation of hie opt-out form typically requires the individual's name, date of birth, contact information, and signature.

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