Please READ the Healthinfonet Educational Materials Before Filling out This Form

HealthInfoNetConsenttoShareMentalHealthandHIV/AIDSRecords

Please READ the HealthInfoNet educational materials before filling out this form

Choosefromthefollowingoptions.

Iwant toinclude mymentalhealth informationin myHealthInfoNetrecord. Iwant to includemy HIV/AIDS informationin my HealthInfoNetrecord.

Iwouldliketoreversemypreviousconsentandhidethefollowinginformation.Chooseoneorboth.

Mental HealthHIV/AIDS

Youcanchoosetodonothingwiththisform.Ifyoudonothing,yourgeneralmedicalinformationwillbeavailabletoparticipatingprovidersandyourmentalhealthand/orHIV/AIDSinformationwillbeavailableonlyinamedicalemergency.

Youcanstillprovideconsentforindividualproviders.Todothis,tellyourparticipatingproviderduringyourvisitthattheyhaveyourconsenttoaccessyourmentalhealth,HIV/AIDSinformationorboth.Theinformationwillbeavailabletothatindividualproviderduringthatvisit.Youwillneedtogivepermissionthenexttimeyouwantthemtohaveaccess.

To remove all your medical information from HealthInfoNet, even in an emergency, you need to fill out a separate opt-out form.TheseareavailablefromyourproviderorHealthInfoNet.

FirstNameMiddleNameLastName

AddressCityStateZipCode

DateofBirth(Month/Day/Year)

Sex(male/female)

DaytimeTelephoneEmail

Bysigning,IunderstandtheinformationI'veindicatedabovewillbeavailabletomyprovidersusingHealthInfoNet.

SignatureofPatientorGuardian

Pleaseincludeprintednameandcontactofguardian

Date(Month/Day/Year)

DooneofthefollowingtogetthisformtoHealthInfoNet

1.Returnthisformtoyourprovider,havethemwitnessbelow,andforwardtoHealthInfoNetbyfaxat207-541-9258ormailto125PresumpscotStreetBox8,Portland,ME04103.

2.Contact HealthInfoNet at 866-592-4352toscheduleatimetocometoHealthInfoNet'sofficeinpersonwithyour government-issuedphotoID.HealthInfoNetislocatedat125PresumpscotStreet,Portland.

3.Ifyoucan'tdooneofthetwofirstoptions,youmaycontactHealthInfoNetandasktobesentaformthatcanbenotarized.

YoucanalsodownloadthisformfromHealthInfoNet'swebsiteat

ProviderorHealthInfoNetWitnessOnly

On//,Iattestthattheabovesignerispersonallyknowntomeorestablishedhis/heridentitybypresentinggovernment-issuedphotoidentification.

SignaturePrintNameEmployer/Organization

Mental Health or HIV/AIDSHealthInfoNetAccess Script

Beforespeakingwiththepatient,checktheirconsentstatusrelativetoMHorHIV/AIDSinformationonthedemographicscreenintheclinicalportal.Thiswilltellyouwhetherthepatienthaschosentoincludethisinformationintheirrecordalreadyaswellasiftheyhavechosentoopteverythingout.Ineitherofthesecases,youdonotneedtousethisscript.

IfthepatienthasnotconsentedtoincludeMHorHIV/AIDSinformationintheirrecord,individualuserscanhaveaccesstothisinformationifthepatientagreesduringthevisit.Thefollowingscriptcanbeusedtorequestconsent.Ifthepatientagrees,theusermustattesttoconsentinportalandaccesstotheinformationselectedwillbeavailableforthatparticularvisitonly.

Patient Script:

(FacilityName)usesHealthInfoNet,asecurestatewidecomputersystemthathelpsusmoreeasilycoordinateyourcare.Iusethissystemtoquicklyseeyourmedicalinformationfromyourotherhealthcareproviderstohelpmemakethebestpossibledecisionaboutyourcare.

RightnowIonlyseeyourgeneralmedicalinformation.Ifyouhaveinformationrelatedto mentalhealthtreatmentorHIV/AIDSyou’dlikemeseetohelpcareforyou,pleaseletmeknow.Ineedyourpermissiontoaccessthisinformation.

IfthepatienthasadditionalquestionsseetalkingpointsandFAQs.