Patient Opt-Out

The medical groups, hospitals, and other healthcare-related entities (Participants) who care for you and related parties who pay for such healthcare services share your health information through Mississippi Health Access Exchange , a secure, electronic Health Information Exchange (HIE)* unless you Opt-Out of Mississippi Health Access Exchange.

If you do not want your health information shared and used through the HIE, complete and submit the form below. By submitting this completed Opt-Out Form you understand and agree that:

  • Your information will not be available to Participants and it may not be available in the event of an emergency. 
  • Participants are not required to remove any health information that was shared with them through the HIE prior to the date of this form being submitted and processed.
  • It may take between 2 - 5 business days to process this Opt-Out form.
  • If you want your health information shared through the HIE in the future, you must complete and submit a Mississippi Health Access Exchange Request to Opt-In Form.
If there are any questions in the processing of your request, a Mississippi Health Access Exchange representative will contact you using the telephone number you provided below.
 
* Mississippi Health Access Exchange is the Health Information Exchange endorsed by the Mississippi State Medical Association and operated by KONZA.
 
ALL FORMS FIELDS BELOW ARE REQUIRED UNLESS NOTED "OPTIONAL."

First Name:

 
Middle Name:


Last Name:

 
DOB:

 
Gender:


Address:

 
City:

 
State:

 
Zip:

 
 
Phone Number:

 
 
Social Security Number (Optional):

 

Patient Email (Optional):

 
Physician/Facility Name (Optional):


Physician office/Facility email (Optional):

 

I am completing this form as a legal representative of the above noted patient.