3. Where Health Information About You Comes From. Information about you comes
from places that have provided you with
medical care or health insurance. These may include hospitals, physicians,
pharmacies, clinical laboratories, health insurers, the
Medicaid program, and other organizations lhat exchange health information
electronically. A complete, current list is available from
Healthix. You can obtain an updated list at any time by checking Healthix’s
website at www.heaIthix.org or by calling (877) 695-4749.
4. Who May Access Information About You, If You Give Consent. Only doctors and
other staff members of the Organization(s) you
have given consent to access who carry out activities permitted by this form as
described above in paragraph one.
5. Public Health and Organ Procurement Organization Access. Federal, state or
local public health agencies and certain organ
procurement organizations are authorized by law to access health information
without a patient's consent for certain public health
and organ transplant purposes. These entities may access your information
through Healthix for these purposes wilhoul regard to
whether you give consent, deny consent or do not fill out a consent form.
6. Penalties for Improper Access to or Use of Your Information. There are
penalties for inappropriate access to or use of your
electronic health information. If at any time you suspect that someone who
should not have seen or gotten access to information about you has done so, call Provider Organization
at: (800) 894-3226; or visit Healthix’s website: www.heaIthix.org; or call the
NYS Department of Health at
(518) 474-4987; or follow the complaint process of the federal Office for Civil Righls at the following link:
7. Re-disclosure of Information. Any organization(s) you have given consent
to access health information about you may re-disclose
your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the
required statements regarding prohibition of re-disclosure.
8. Effective Period. This Consent Form will remain in effect until the day you change your consent choice, death or until such time as Healthix ceases operation. If Healthix merges with another Qualified Entity your consent choices will remain effective with the newly merged entity.
9. Changing Your Consent Choice. You can change your consent choice at any time
and for any Provider Organization or Health
Plan by submitting a new Consent Form with your new choice. Organizations that access your health information through Healthix while your consent is in effect may copy or include your information in their
own medical records. Even if you later decide to change
your consent decision they are not required to return your information or remove it from their records.
10. Copy of Form. You are entitled to get a copy of this Consent Form.