Model Rhio Consent Form

HealtheConnections™Consent Form Veterans Health Administration Syracuse VA Medical Center

800 Irving Avenue SyracuseNewYork

InthisConsentForm,youcanchoosewhethertoallowtheVeteransHealthAdministrationtoobtainaccesstoyourmedicalrecordsthroughacomputernetwork operatedbyHealtheConnections™,whichispartofastatewidecomputernetwork.Thiscanhelpcollectthemedicalrecordsyouhaveindifferentplaceswhere yougethealthcare, andmakethemavailableelectronicallytoouroffice.

YoumayusethisConsentFormtodecidewhetherornottoallow VeteransHealth Adminstrationstafftoseeandobtainaccesstoyourelectronichealthrecordsinthisway.Youcangiveconsentordenyconsent,andthisformmaybefilledoutnoworatalaterdate.Yourchoicewillnotaffectyourabilitytogetmedicalcareorhealthinsurancecoverage.Yourchoicetogiveortodenyconsent maynotbethebasisfordenialofhealthservices.

Ifyoucheckthe“IGIVECONSENT”boxbelow,youaresaying“Yes,VeteranHealthAdministrationstaffinvolvedinmycaremayseeandgetaccesstoallofmymedicalrecordsthroughHealtheConnections™.”

Ifyoucheckthe“IDENYCONSENT”boxbelow,youaresaying“No,VeteranHealthAdministrationstaffmaynotbegivenaccesstomymedicalrecordsthroughHealtheConnections™foranypurpose.”

HealtheConnections™isanot-for-profitorganization.Itsharesinformationaboutpeople’shealthelectronicallyandsecurelytoimprovethequalityofhealthcareservices.Thiskindofsharingiscalledehealthorhealthinformationtechnology(healthIT).TolearnmoreaboutehealthinNewYorkState,readthebrochure,“BetterInformationMeansBetterCare.”YoucanasktheVeteranHealthAdministrationforit,orgotothewebsite

Pleasecarefullyreadtheinformationonthebackofthisformbeforemakingyourdecision.YourConsentChoices.Youcanfilloutthisform noworinthefuture.Youhave twochoices:

IGIVECONSENTfortheVeteransHealthAdministrationtoaccessALLofmyelectronichealthinformationthrough HealtheConnections™inconnectionwithprovidingmeanyhealthcareservices,includingemergencycare.

IDENYCONSENTfortheVeteransHealthAdministrationtoaccessmyelectronichealthinformationthroughHealtheConnections™foranypurpose,eveninamedicalemergency.NOTE:UNLESSYOUCHECKTHIS

BOX,NewYorkStatelawallowsthepeopletreatingyouinanemergencytogetaccesstoyourmedical

records,includingrecordsthatareavailablethroughHealtheConnections™.

PrintNameofPatient

PatientDateofBirth

FullSocialSecurityNumber

SignatureofPatientorPatient’sLegalRepresentative

Date

PrintNameofLegalRepresentative(ifapplicable)

RelationshipofLegalRepresentativeto

Patient(ifapplicable)

DetailsaboutpatientinformationinHealtheConnections™andtheconsentprocess:

1.HowYourInformationWillbeUsed.YourelectronichealthinformationwillbeusedbytheVeteransHealth

Administration onlyto:

• Provideyouwithmedicaltreatmentandrelatedservices
• Evaluateandimprovethequalityofmedicalcareprovidedtoallpatients.

NOTE:ThechoiceyoumakeinthisConsentForm doesNOTallowhealthinsurerstohaveaccesstoyourinformationforthepurpose ofdecidingwhethertogiveyouhealthinsurance orpayyourbills.Youcanmakethat choiceina separateConsentForm that healthinsurers mustuse.

2.WhatTypesofInformationaboutYouAreIncluded.Ifyougiveconsent,theVeteransHealthAdministrationmayaccessALLofyourelectronichealthinformationavailablethroughtheRHIO.ThisincludesinformationcreatedbeforeandafterthedateofthisConsentForm.Yourhealthrecordsmayincludeahistoryofillnessesorinjuriesyouhavehad(likediabetesorabrokenbone),testresults(likeX-raysorbloodtests),andlistsofmedicinesyouhavetaken.Thisinformationmayrelatetosensitivehealthconditions,includingbutnotlimitedto:

• Alcoholordruguseproblems/treatment
• Birthcontrolandabortion(familyplanning)
• Genetic(inherited)diseasesortests
• AnymentionofHIV/AIDS
• Mentalhealthconditions
• Sexuallytransmitteddiseases

3.WhereHealthInformationAboutYouComesFrom.Informationaboutyoucomesfromplacesthathaveprovidedyouwithmedicalcareorhealthinsurance(“InformationSources”).Thesemayincludehospitals,physicians,pharmacies,clinicallaboratories,healthinsurers,theMedicaidprogram,andotherehealthorganizationsthatexchangehealthinformationelectronically.AcompletelistofcurrentInformationSourcesisavailablefrom HealtheConnections™.YoucanobtainanupdatedlistofInformationSourcesatanytimebycheckingtheHealtheConnections™websiteat

4.WhoMayAccessInformationAboutYou,IfYouGiveConsent.Onlythesepeoplemayaccessinformationaboutyou:doctorsandotherhealthcareproviderswhoserveonthe VeteransHealthAdministrationmedicalstaffwhoareinvolvedinyourmedicalcare;healthcareproviderswhoarecoveringoroncallfortheVeteransHealthAdministrationdoctors;andstaffmemberswhocarryoutactivitiespermittedbythisConsentFormasdescribedaboveinparagraphone.

5. PenaltiesforImproper AccesstoorUseofYourInformation.Therearepenaltiesforinappropriateaccessto oruseof yourelectronichealthinformation.Ifatanytimeyoususpectthatsomeonewhoshouldnothaveseenorgottenaccesstoinformationaboutyouhasdoneso,calltheVeteransHealthAdministration:(315)425-4400;orvisitHealtheConnections™website:

6.Re-disclosureofInformation.Anyelectronichealthinformationaboutyoumaybere-disclosedbytheVeteransHealthAdministrationtoothersonlytotheextentpermittedbystateandfederallawsandregulations.Thisisalsotrueforhealthinformationaboutyouthatexistsinapaperform.Somestateandfederallawsprovidespecialprotectionsforsomekindsofsensitivehealthinformation,includingHIV/AIDS,mentalhealthinformationanddrugandalcoholtreatment.Theirspecialrequirementsmustbefollowedwheneverpeoplereceivethesekindsofsensitivehealthinformation.HealtheConnections™andpersonswhoaccessthisinformationthrough

iHealtheConnections™mustcomplywiththeserequirements.

7.EffectivePeriod.ThisConsentFormwillremainineffectuntilthedayyou withdrawyourconsentorHealtheConnections™ceasesalloperations.

8.WithdrawingYourConsent.YoucanwithdrawyourconsentatanytimebysigningaWithdrawalofConsentFormandgivingittotheVeteransHealthAdministration.YoucanalsochangeyourconsentchoicesbysigninganewConsent

Formatanytime.YoucangettheseformsontheHealtheConnections™websiteat

9.CopyofForm.YouareentitledtogetacopyofthisConsentForm after yousignit.

2