HEALTH INFORMATION EXCHANGE, CARE EVERYWHERE AND HEALTHIX CONSENT FORM cts Consent Form, you can choose whether to allow the heaith care providers listed on the NYU Langone Medical Center Health Information Exchange (“NYUL Health HIE") website http: | (HIE Participants") and non- NYU health care providers who may request access to your medical records for purposes of current treatment (‘Care Everywhere Providers’) to obtain access to your medical records through a computer network operated by the NYUL Health You may also use this Consent Form to decide whether or not to allow employees, agents or members of the medical staff of NYU Hospitals Center to see and obtain access to your electronic health records through Healthix. which is a Heain information Exchange, or Regional Health Information Organization (RHIO), a not-for-profit organization recognized by the prowicers authorized to disclose information through Healthix. A complete list of current Healthix Information Sourose 1s saline Houma, iealthix and can be obtained at any time by checking the Healthix website at hito/ivww healthix ong or by calling Healthix at 877-695-4749, Upon request, your provider will print this list for you from the Heaithix website. YOUR CHOICE WILL NOT AFFECT YOUR ABILITY TO GET MEDICAL CARE OR HEALTH INSURANCE COVERAGE, YOUR CHOICE TO GIVE OR TO DENY CONSENT MAY NOT BE THE BASIS FOR DENIAL OF HEALTH SERVICES. about eneath in New York State, read the brochure, “Better information Means Better Care” You can ask your health care provider for it, or go to the website www.ehealth4ny org. PLEASE CAREFULLY READ THE INFORMATION ON THE FACT SHEET BEFORE MAKING YOUR DECISION. Your Consent Choices. You can fill out this form now or in the future. You have the following choices: , Please check one box I ce CT] Care Everywhere Providers to access ALL of my electronic health information through the NYUL Health Center to access ALL of my electronic health information through HEALTHIX in connection with any of the permitted purposes described in the fact sheet, including providing me any health care services, including emergency care. 2. | DENY CONSENT to ALL of the HIE Participants listed on the NYUL Health HIE website and Care Everywhere Providers to access my electronic health information through the NYUL Health MIE» HEALTHIX for any purpose, even in a medical emergency 3 OTE: UNLESS YOU CHECK THE “I DENY CONSENT” BOX, New York State law allows the people treating you in an TF yOu Cemeget access to your medical records, including records that are available through the NYUL Health Hie, iF YOU DON'T MAKE A CHOICE, the records will not be shared except in an emergency a8 allowed by New York State Law. SEEREN EPS 1-30-9452 PRINT Name of Patient Patient Date of Birth t -il- | y Signature of Patient or Patient's Legal Representative Date Print Name of Legal Representative (it applicable) Relationship of Legal Representative to Patient (if applicable) EFTA00313916