Health Information Exchange Notice

How Your Information May Be Used

When you provide consent, your electronic health information will be securely shared and used by the organizations, providers, or affiliates as set forth above only to:

• Provide you with medical treatment and related services.
• Evaluate and improve the quality of medical care provided to all patients.

Types of Information Included and Where It Comes From

The information about you comes from participating organizations that have provided you with medical care. These may include hospitals, physicians, pharmacies, clinical laboratories, and other healthcare organizations and may include information created before the date of this Consent Form. HIE may contain a history of your illnesses or injuries, test results, and lists of medications your doctor has prescribed. This information may include sensitive health conditions, including, but not limited to:

• Alcohol or drug use problems
• Birth control and abortion (family planning)
• Genetic (inherited) diseases or tests
• HIV/AIDS
• Mental health conditions
• Sexually transmitted infections/diseases
• Medication and dosages
• Substance use history summaries
• Clinical notes, illnesses/injuries/allergy history
• Discharge summary
• Employment information
• Living situation/social supports
• Claims encounter data
• Lab test and diagnostic results

Who May Access Information About You

By consenting, only doctors, medical staff members, employees, trainees, students, volunteers, and agents of the Organization(s) you have given consent to, may access your health information to carry out activities permitted in this form as described above.

Improper Access or Use of Your Information

There are penalties for inappropriate access to or use of your electronic health information. If at any time you suspect that someone who should not have seen or obtained access to your personal information, you can contact the Everside Health Privacy Officer by writing to: Everside Health, Privacy Officer, 1400 Wewatta Street, Suite 350 Denver CO 80202 or by email at privacy@eversidehealth.com.

Re-disclosure of Information

Any organization(s) you have given consent to access HIE may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure.

Effective Period

Your Consent becomes effective upon signing this form and will remain in effect until the day you change or revoke your consent choice, death. If consent is signed by a parent or legal guardian of a minor, the consent decision will expire on the 18th birthday when the minor becomes an adult, and the patient will have to file a new consent decision.

Changing or Revoking Your Consent Choice

You can change or revoke your consent at any time by signing a new Consent Form indicating your new choice. You can get the Consent Form from your provider or by contacting Everside Health Member Services. Changes to your consent status may take up to 72 hours to become active in the system.

Copy of Records and Consent Form

Organizations, including any providers that participate in a HIE, that access your health information, may save, copy, or include your information in their own medical records while your consent is in effect. Even if you later decide to withdraw your consent, they are not required to return it or remove it from their records. You are entitled to get a copy of this Consent Form at any time.

How your information is protected

Federal and state laws and regulations protect your medical information. HIPAA, the Healthcare Insurance Portability and Accountability Act of 1996, is the federal law that protects your medical records and limits who can look at and receive your health information, including electronic health information. HIPAA’s protections were further strengthened by another federal law, the HITECH Act of 2009, which may impose severe financial fines on anyone who violates your medical privacy rights. All health information made available on the HIE, including your medical information, is encrypted to federal standards. In addition, your Provider must provide you with a Notice of Privacy Practices, which describes how he or she uses and protects your medical information.

HIE Opt Out

To opt out of this program, please download and fax a copy of this form (links to PDF) to Everside Health’s Member Services team.