53Make an eConsent DecisionMake an eConsent DecisionPublished2013-01-23 14:12:19 UTCfalse<h3> </h3>
<table border="0" cellpadding="3" align="left"><tbody>
<tr>
<td> </td>
<td>
<h2> eConsent Choice Information</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h3>Please carefully read the information that follows before making your decision.</h3>
<p>You may use this Consent Decision to decide whether or not to allow Participating HIE Providers and Payers ("Participants") who are involved in your care to see and obtain access to your electronic health records for treatment and/or care management purposes. This form may be filled out now or at a later date. You can give consent or deny consent to some or all of the Participants. </p>
<p><strong>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.</strong></p>
<p>In this Consent Decision, you can choose whether to allow the Participants to obtain access to your medical records through a computer network operated by HIE, which is a part of a statewide healthcare computer network. This helps collect the medical records you have in different places where you get health care, and make them available electronically to the Participants rendering services to you.</p>
<div class="info">
<h4>How Your Information Will Be Used</h4>
<p>Your electronic health information will be used by the Participating you approve only for:</p>
<p>Quality Improvement Activities: These include evaluating and improving the quality of medical care provided to you and all of the health insurer's members.</p>
<p>Care Management Activities: These include assisting you in obtaining appropriate medical care, improving the quality of health care services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical care.</p>
<p>Pre-Authorization Activities: These include reviewing and evaluating medical information in order to pre-approve services requested by you or your health care provider.</p>
<p><strong>Penalties for Improper Access to or Use of Your Information.</strong> There are penalties for inappropriate access to or use of your electronic health information.</p>
<p><strong>Withdrawing Your Consent.</strong> You can withdraw your consent at any time by signing a Withdrawal of Consent Decision and giving it to one of the Participants. You can also change your consent choices by signing a new Consent Decision at any time.</p>
<p><strong>What Types of Information about You Are Included.</strong> If you give consent, the Participants you approve may access ALL of your electronic health information available through HIE. This includes information created before and after the date of this Consent Decision. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This information may relate to sensitive health conditions, including but not limited to:</p>
<ul>
<li>Birth control and abortion (family planning)</li>
<li>Sexually transmitted diseases</li>
</ul>
<p><strong>Where Health Information About You Comes From.</strong> Information about you comes from places that have provided you with medical care or health insurance ("Information Sources"). These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, the Medicaid program, and other ehealth organizations that exchange health information electronically.</p>
</div>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
</tbody></table><h3> </h3>
<h3> </h3>
<p> </p>251eConsent Choice Informationfalsefalse<table border="0" cellpadding="3" align="left"><tbody>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td>
<h2>eConsent Choice Options</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h4>Yes</h4>
</td>
<td>I GIVE CONSENT for all Participants who are <span style="text-decoration: underline;">involved in my care</span> to access ALL of my electronic health information through HIE. By checking this box you agree that, "Yes, the staff involved in my care including emergency care, quality improvement, care management, and pre-authorization activities at all the Participants may see and get access to all of my medical records through HIE.</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h4>Yes, except</h4>
</td>
<td>
<p>I GIVE CONSENT for all Participants who are <span style="text-decoration: underline;">involved in my care</span> to access ALL of my electronic health information through HIE except the following Participants, (paper form required)</p>
<p>These Participants cannot access my electronic health information via HIE <strong>EXCEPT in a medical emergency.</strong> If you have chosen to exclude any Participants, you <strong>must</strong> contact HIE to verify your form. If you wish to deny consent to additional Participants, please identify them on the Participant Exclusion Form.</p>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h4>No, except</h4>
</td>
<td>I DENY CONSENT for all Participants <span style="text-decoration: underline;">who are involved in my care</span> to access my electronic health information through HIE for any purpose, <strong>EXCEPT in a medical emergency.</strong> By checking this box you agree, "No, none of the Participants may be given access to my medical records through HIE unless it is a medical emergency."</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h4>No, never</h4>
</td>
<td>I DENY CONSENT for all Participants access my electronic health information through HIE for any purpose, <strong>INCLUDING in a medical emergency.</strong>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
</tbody></table><h4> </h4>
<h4> </h4>
<h4> </h4>
<div class="span8"> </div>
<div class="span8"> </div>
<div class="span8"> </div>
<div class="span8"> </div>
<div class="span8"> </div>
<div class="span8"> </div>
<div class="span8"> </div>
<h4> </h4>
<div class="span8"> </div>
<h4> </h4>
<div class="span8"> </div>252eConsent Choice Optionsfalsefalse<table border="0"><tbody>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2>eConsent Choice</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2> </h2>
<h2>Yes<span style="font-size: small;"><br></span>
</h2>
<p><span style="font-size: small;">I GIVE CONSENT for all Participants who are <span style="text-decoration: underline;">involved in my care</span> to access ALL of my electronic health information through HIE. By signing this agreement you agree that, "Yes, the staff involved in my care including emergency care, quality improvement, care management, and pre-authorization activities at all the Participants may see and get access to all of my medical records through HIE."</span></p>
<p> </p>
</td>
<td> </td>
</tr>
</tbody></table><h4> </h4>
<div class="span8"> </div>253eConsent Choice Signature Yestruefalse<table border="0"><tbody>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2>Consent Decision Confirmed</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<p><span style="font-size: small;">We have recorded your decision as</span></p>
<h3>Yes</h3>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td><span style="font-size: small;">I GIVE CONSENT for all Participants who are <span style="text-decoration: underline;">involved in my care</span> to access ALL of my electronic health information through HIE. By checking this box you agree that, "Yes, the staff involved in my care including emergency care, quality improvement, care management, and pre-authorization activities at all the Participants may see and get access to all of my medical records through HIE."</span></td>
<td> </td>
</tr>
</tbody></table><div class="span8"> </div>
<div class="span8"> </div>280eConsent Choice Signature Yes Displayfalsetrue<table border="0"><tbody>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2>eConsent Choice</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2> </h2>
<h2>No, except</h2>
<p> <br><span style="font-size: small;">I DENY CONSENT for all Participants <span style="text-decoration: underline;">who are involved in my care</span> to access my electronic health information through HIE for any purpose, <strong>EXCEPT in a medical emergency.</strong> By checking this box you agree, "No, none of the Participants may be given access to my medical records through HIE unless it is a medical emergency."</span></p>
<h2> </h2>
</td>
<td> </td>
</tr>
</tbody></table><h4> </h4>
<div class="span8"> </div>282eConsent Choice Signature Emergencytruefalse<table border="0"><tbody>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2>eConsent Choice</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2> </h2>
<h3>Yes<span style="font-size: small;">,</span> except</h3>
<p> </p>
<p><span style="font-size: small;">I GIVE CONSENT for all Participants who are <span style="text-decoration: underline;">involved in my care</span> to access ALL of my electronic health information through HIE except the following Participants, (paper form required)</span></p>
<p><span style="font-size: small;">These Participants cannot access my electronic health information via HIE <strong>EXCEPT in a medical emergency.</strong> If you have chosen to exclude any Participants, you <strong>must</strong> contact HIE to verify your form. If you wish to deny consent to additional Participants, please identify them on the Participant Exclusion Form.</span></p>
<h2> </h2>
</td>
<td> </td>
</tr>
</tbody></table>281eConsent Choice Signature Excepttruefalse<table border="0"><tbody>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2>eConsent Choice</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2> </h2>
<h2>No, never</h2>
<p> <br><span style="font-size: small;">I DENY CONSENT for all Participants access my electronic health information through HIE for any purpose, <strong>INCLUDING in a medical emergency.</strong></span></p>
<h2> </h2>
</td>
<td> </td>
</tr>
</tbody></table><h4> </h4>
<div class="span8"> </div>283eConsent Choice Signature Notruefalse<table border="0"><tbody>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2>Consent Decision Confirmed</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<p><span style="font-size: small;">We have recorded your decision as</span></p>
<h3>No, except</h3>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td><span style="font-size: small;">I DENY CONSENT for all Participants <span style="text-decoration: underline;">who are involved in my care</span> to access my electronic health information through HIE for any purpose, <strong>EXCEPT in a medical emergency.</strong> By checking this box you agree, "No, none of the Participants may be given access to my medical records through HIE unless it is a medical emergency."</span></td>
<td> </td>
</tr>
</tbody></table><div class="span8"> </div>285eConsent Choice Signature Emergency Displayfalsetrue<table border="0"><tbody>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2>Consent Decision Confirmed</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<p><span style="font-size: small;">We have recorded your decision as</span></p>
<h3>Yes, except</h3>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<p><span style="font-size: small;">I GIVE CONSENT for all Participants who are <span style="text-decoration: underline;">involved in my care</span> to access ALL of my electronic health information through HIE except the following Participants, (paper form required)</span></p>
<p><span style="font-size: small;">These Participants cannot access my electronic health information via HIE <strong>EXCEPT in a medical emergency.</strong> If you have chosen to exclude any Participants, you <strong>must</strong> contact HIE to verify your form. If you wish to deny consent to additional Participants, please identify them on the Participant Exclusion Form.</span></p>
</td>
<td> </td>
</tr>
</tbody></table><div class="span8"> </div>284eConsent Choice Signature Except Displayfalsetrue<table border="0"><tbody>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<h2>Consent Decision Confirmed</h2>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td>
<p><span style="font-size: small;">We have recorded your decision as</span></p>
<h3>No, never</h3>
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td><span style="font-size: small;">I DENY CONSENT for all Participants access my electronic health information through HIE for any purpose, <strong>INCLUDING in a medical emergency.</strong></span></td>
<td> </td>
</tr>
</tbody></table><div class="span8"> </div>286eConsent Choice Signature No Displayfalsetrue196251153cta-yellow2013-01-23T14:53:28Z67621196I'm Ready To Make My Consent Decision1972013-01-23T14:53:28Zcta-blue2013-01-23T14:54:28Z67722196Take SurveyI Do Not Want to Make a Consent Decision Now352013-01-23T14:54:28Z197252253cta-blue2013-01-23T14:55:27Z67821197Yes1982013-02-12T17:23:23Zcta-blue2013-02-12T17:20:25Z84822197Yes, except2272013-02-12T17:22:54Zcta-blue2013-02-12T17:20:45Z84923197No, except2262013-02-12T17:23:01Zcta-blue2013-02-12T17:21:00Z85024197No, never2282013-02-12T17:21:00Z198253353cta-blue2013-02-06T22:42:49Z83621198Record My Consent Decision2252013-02-06T22:42:49Zcta-gray2013-02-06T22:43:20Z83732198Change My Consent Choice1972013-02-06T22:43:20Z225280453cta-blue2013-02-12T17:15:30Z83821225Exit, Start Survey352013-02-12T17:18:31Z226282753cta-blue2013-02-12T17:17:33Z84221226Record My Consent Decision2292013-02-12T17:17:33Zcta-gray2013-02-12T17:17:52Z84332226Change My Consent Choice1972013-02-12T17:17:52Z227281553cta-blue2013-02-12T17:15:57Z83921227Record My Consent Decision2302013-02-12T17:15:57Zcta-gray2013-02-12T17:16:19Z84032227Change My Consent Choice1972013-02-12T17:16:19Z228283953cta-blue2013-02-12T17:19:04Z84521228Record My Consent Decision2312013-02-12T17:19:04Zcta-gray2013-02-12T17:19:21Z84632228Change My Consent Choice1972013-02-12T17:19:21Z229285853cta-blue2013-02-12T17:18:22Z84421229Exit, Start Survey352013-02-12T17:18:49Z230284653cta-blue2013-02-12T17:16:51Z84121230Exit, Start Survey352013-02-12T17:18:40Z2312861053cta-blue2013-02-12T17:19:37Z84721231Exit, Start Survey352013-02-12T17:19:37Z