NYUlaneone Hearth HEALTH INFORMATION EXCHANGE, CARE EVERYWHERE AND HEALTHIX CONSENT FORM Health In this Consent Form. you can choose whether to allow the headh care providers listed on the NYU Langone Medical Center NYU Information health Exchange ('NYUL Health HIE') website http lehealth-Ohnect.rried nvu.edu ("HIE Participants') and nonEverywhere Providers') care providers who may request access to your medical records for purposes of current treatment (tare HIE. In order to obtain access to your medical records through a computer network operated by the NYUL Health must for a Care EveryMere Provider to know that information may be available through the NYUL Health HIE, you This can tell them help collect that you werelare a patient of an HIE Participant and that such information may be available upon request. available electronically the medical records you have in different places where you get heath care. and make them to the providers treating you NYU You may Hospitals also use Center this Consent Form to decide whether or not to allow employees. agents or members of the medical staff of Information Exchange. to see and obtain access to your electronic health records through Heather. which is a Health state of New York This or can Regional also help Heath Information Organization (RHIO). a not-for-profit organization recognized by the make them available electronically collect the medical records you have in different places where you get healthcare. and Langone Heath program to the providers treating you. This consent also gives your permission for any NYU providers authorized in which you are a patient or member to access your records from your other healthcare to disclose available from Healthix and information through Hes!Utz. A complete list of current Healthix Information Sources is calling Heather at 877-695-4749. can be Upon obtained at any time by checking the Healthix website at gto:/r~ healthy( Ora or by request. your provider will print this list for you from the HeaAtha website. YOUR YOUR CHOICE CHOICE TO WILL GIVE NOT OR AFFECT YOUR ABILITY TO GET MEDICAL CARE OR HEALTH INSURANCE COVERAGE. TO DENY CONSENT MAY NOT BE THE BASIS FOR DENIAL OF HEALTH SERVICES. of The hearth NYUL care Health services. HIE and This Healthy( share information about peoples health electronically and securely to improve the quality kind of sharing is called ehealth or health Information about eheafth technology (health IT) To learn more provider for it, or in New go York State. read the brochure. 'etter Information Means Better Care' You can ask your health care to the website Aww.ehealth4tWdrd PLEASE Your Consent CAREFULLY Choices READ THE INFORMATION ON THE FACT SHEET BEFORE MAKING YOUR DECISION. You can fill out this form now or in the future. You have the following choices Please check one box 2 below. • • Care 1. I Everywhere GIVE CONSENT Providers to ALL of the HIE Participants listed on the NYUL Health HIE website and HIE and to access ALL of my electronic heath information through the NYUL Health Center I GIVE CONSENT to ALL employees, agents and members of the medical staff of NYU Hospitals permitted to access purposes ALL of my electronic health information through HEALTHIX in connection with arty of the emergency described in the fact sheet including providing me any health care services, "eluding care. Care 2. I DENY Everywhere CONSENT Providers to ALL of the HIE Participants listed on the NYUL Health HIE website and HEALTHIX to access my electronic health information through the NYUL Health HIE or for any purpose, even en a medical emergency emergency NOTE: UNLESS to get YOU access CHECK THE "I DENY CONSENT" BOX, New York State law allows the people treating you in an IF YOU DON'T MAKE A CHOICE, to your medical records, including records that aro available through the NYUL Health HIE. State Law. the records will not be shared except In an emergency as allowed by New York PRINT Tf r Name . Pt -t-N ( -reff•--1 19s2 of Patient Patient Date of Birth Signature of Patient or Patient's Legal Representative Date Print Name of Legal Representative (if applicable) Relationship of Legal Representative to Patent (if applicable) EFTA00313916