www.wishin.org

HealthInformationExchange:AGUIDETOPATIENTCHOICE

WhatIsaHealthInformationExchange?Healthinformationexchange(HIE)isawaytoshareyouressentialhealthinformationamongparticipatingdoctors’offices,hospitals,labs,radiologycentersandotherhealthcareprovidersthroughsecure,electronicmeans.TheWisconsinStatewideHealthInformationNetwork,Inc.(WISHIN)waschosenbythestateofWisconsintogovernandimplementourstate’shealthinformationexchange,whichiscalledWISHINPulse.WISHINPulsehelpseveryparticipatingprovideryouseegaintimelyaccesstoamorecompleteandaccuratehealthrecord.Thathelpsyourdoctorsandothercaregiversworktogethermoreeasily,makebetterdecisionsaboutyourcare,eliminateredundantformsortests,andreducemistakes—especiallyinanemergencyorforprovidersoutsideyourtypicalhealthnetwork.

IsSharingHealthInformationSomethingNew?No.Today,healthinformationisfrequentlysharedbetweendoctorsthroughphonecalls,faxesorUSmail.WISHINPulseallowsthissameinformationtobesharedsecurelyandelectronically—makingitmorecost-effective,timelyandefficientthancurrentpaper-basedmethods.

WhatInformationIsinWISHINPulse?WISHINPulseincludesessentialhealthinformationfromhealthcareproviderswhohavetreatedyouandareWISHINparticipants.Thatinformationincludesmedications,allergies,currentandpasttestresults,andsummariesofpastandcurrenthealthproblems.WISHINPulsecanprovideasummaryviewofthisinformation,whichwillenablebetterdecisionsaboutyourhealthcare.

HowIsMyInformationProtected?WISHINPulsecarefullyprotectstheprivacyandsecurityofyourrecords.First,WISHINandallparticipatingWISHINprovidersmustcomplywiththepolicies,proceduresandregulationsestablishedbytheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA)aswellasotherapplicablelawsandregulations.Somehealthinformation(suchasmentalhealth,alcoholordrugtreatments,etc.)requiresadditionalwrittenconsentfromyoubeforeitcanbesharedwithyourdoctor,exceptinanemergency.Onlythoseinvolvedinyourcarewillbeabletoviewyourhealthinformation,andonlywhenneededtoprovideorcoordinateyourcare,makereferralsorsubmitrequiredpublichealthinformation(suchasyourvaccinationhistory).Auditlogs,reportsandothersecuritymeasuresshowhowhealthinformationhasbeenaccessedorexchanged.Thesereportssupportcompliancewiththestrictfederalandstateguidelinesthatgovernhowandwhenyourhealthinformationcanbeexchanged,viewedorused.Informationthatidentifiesyouwillneverbesoldormadeavailableforotherpurposes.Together,thesesecuritymeasuresmakeanelectronichealthinformationexchangemoresecurethantoday’spaper-basedexchangemethodssuchasfaxorcourier.

WhoIsWISHIN?TheWisconsinStatewideHealthInformationNetwork(WISHIN)isanindependentnot-for-profitorganizationdedicatedtobringingthebenefitsofhealthinformationtechnologytopatientsandcaregiversthroughoutWisconsin.WISHINisbuildingastatewidehealthinformationnetworktoconnectphysicians,clinics,hospitals,pharmaciesandclinicallaboratoriesacrossWisconsin.

Ourvisionistopromoteandimprovethehealthof individualsandcommunitiesinWisconsinthroughthedevelopmentofinformation-sharingservicesthatfacilitateelectronicdeliveryoftherighthealthinformationattherightplaceandrighttimetotherightindividuals.

Wisconsin Statewide Health Informati on NetworkPOBox259038Madison,WI53725-9038Phone:1.888.WISHIN1|Email:wishin@wishin.org

Opt-Out StipulationsYou must read, understand and accept these stipulations in order to officially opt out. You must initial your Patient Choice Form, under Opt-Out Certification, to indicate your acceptance.1.IUNDERSTANDthatthisrequestonlyappliestosharingmyhealthinformationthroughWISHINPulse.IUNDERSTANDthatwhenIseeahealthcareproviderfortreatment,thatprovidermayrequestandreceivemymedicalinformationfromotherprovidersusingothermethodspermittedbylaw,suchasfaxormail.IamawarethathealthcareproviderswhooriginallyrecordedinformationaboutmemaycontinuetohaveaccesstothisinformationthroughmeansotherthanWISHINPulse.

2.IUNDERSTANDthatoncemyopt-outrequestgoesintoeffect,itwillremainineffectunlessIchangeitinwritingbysubmittinganopt-back-inrequesttoWISHINviaaPatientChoiceForm.

3.IhavehadanopportunitytoaskandreceiveanswerstoallmyquestionsaboutoptingoutofWISHINPulse.

4.AnyinformationthatisdisclosedbeforeIsubmitthisopt-outrequestcannotbetakenbackandmayremainwithmyprovider ifhe/sheaccessedsuchinformationbeforethisrequestwentintoeffect.

5.Thisrequest,andanyfuturerequesttooptbackin,cantakeuptothreebusinessdaysafterreceiptbyWISHINtotakeeffect.

6.IUNDERSTANDthatthisWISHINPulseopt-outrequestdoesNOTcoveroraffectmyoptingoutofanyotherhealthinformationexchanges,includingotherexchangetechnologiesofferedbyWISHIN.

7.IUNDERSTANDthatifIwishtooptoutofanotherhealthinformationexchange,Imustfollowtheinstructionsoftheothersuchexchangestolimitmyparticipation.

8.IUNDERSTANDandaccepttherisksassociatedwithdenyinghealthcareprovidersaccesstomyhealthinformationthrough WISHINPulse.

9.IUNDERSTANDthatIcanrevokethisrequestatanytime.

Patient Choice FormTotakepartinWISHINPulse,youdon’tneedtodoanything.Thisformisrequiredonlyfortwocircumstances:1.YouchooseNOTtoallowyourhealthinformationtobeexchangedthroughWISHINPulse(i.e.,youchoosetooptout),or

2.YouhadpreviouslychosentooptoutbutwouldliketochangethatdecisionandoptbackinsothatyourdoctorscansecurelyaccessyourhealthinformationthroughWISHINPulse.

Do I Have a Choice?Yes;youdecideifyouwishtoparticipateornot,andyoucanchangethatdecisionatanytime. If you want to be sure that your providers have timely and secure access to your health information electronically through WISHIN Pulse, you don’t have to do a thing. Participation is automatic.However,youcanchooseNOTtoparticipateinWisconsin’shealthinformationexchange.ThatmeansyourdoctorswillnotbeabletoaccessyourhealthinformationthroughWISHINPulsetousewhiletreatingyou,exceptincasesofanemergency,forpublichealthreportingaspermittedbylaw,andforyourmedicationlist.Thisiscalled“optingout.”Ifyouoptout,youmustaccepttherisksassociatedwithdenyingyourdoctorsaccesstoyourhealthinformationthroughWISHINPulse(seeOpt-OutStipulations).Tooptout,youmustcompleteandsubmittheattachedPatientChoiceForm.Itmaytakeuptothreebusinessdaysafterwereceiveyourformbeforeyouropt-outrequestwilltakeeffect.YouwillreceiveconfirmationofyourrequestbymailfromtheWisconsinStatewideHealthInformationNetwork(WISHIN).Retainthatconfirmationforyourrecords.Ifyoudonotreceiveconfirmation,contactWISHINSupportat1-888-WISHIN1assoonaspossible.Allinformationfieldsmustbecompleted.Foryourprotection,eachrequestreceivedissubjecttoverification.Incompleteformsmayresultinadditionaldelayordenialofyourrequest.AccesstoyourhealthinformationthroughWISHINPulse willberestrictedassoonasispractical.Needmoreinformationbeforemakingyourdecision?Visit www.wishin.org, call 1-888-WISHIN1 or email wishin.support@wishin.org.

Patient Choice FormYou must complete the entire Patient Choice Form and have your signature witnessed by a friend or family member. Forms cannot be processed without a witness’s signature.Please mail completed forms to:WISHIN Attn: Opt-Out Request PO Box 259038 Madison, WI 53725-9038

OPT-OUTREqUEST:IwishtoOPTOUTofhavingmyessentialhealthinformationsharedthroughWISHINPulse.Iunderstandthatbymakingthisdecision,doctorsandcaregiverswillnotbeabletoaccessmyhealthinformationthroughWISHINPulse,exceptincasesofamedicalemergencyorasnecessarytoreportspecificinformationtoagovernmentagencyaspermittedbylaw(forexample,reportingofcertaincommunicablediseasesorsuspectedincidentsofabuse).

OPTBACKIN:IwishtoterminatemypreviousrequesttooptoutofhavingmyessentialhealthinformationsharedthroughWISHINPulse.Myhealthinformationwillbeavailabletomydoctorsandcaregivers.

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PleasePrint

*Full Name: First/Middle/Last

*Date of Birth: Month/Date/Year

*Gender:

Male⃝ Female⃝

*Street Address:

Opt-Out Certification Reason for Opt-Out Request:

Pleaseinitialhere______tocertifythatyouhavereadandaccepttheopt-outstipulationsinthisbrochure.

*City/State/ZIP:

*Signature of Patient (or Authorized Representative) *Date

For your protection, WISHIN requires a witness’ signature to help verify your identity. The witness can be anyone who can confirm you signed the form.

*Signature of Witness *Date *Relationship to Patient

Ifyouarecompletingthisrequestasthepersonalrepresentativeforanotherpatient,youmustalsoprovidethefollowinginformationaboutyourself:

*Relationship to Patient: Title: *First Name: *Middle Name: *Last Name: Suffix(Mr./Mrs./Miss/Ms./Dr.):

*Address: *City/State/ZIP:

Email Address: *Primary Phone: Alternate Phone:

(Confirmation of this request will be sent to the email address listed here)

*Preferredmethodofcontact–checkonlyone(incaseWISHINrequiresadditionalinformationtoimplementyourrequest):

(XXX)XXX-XXXX (XXX)XXX-XXXX

*Phone #: (XXX)XXX-XXXX

Mail⃝ Email⃝ PrimaryPhone⃝ ⃝AlternatePhone

(Jr.,Sr.,III,etc.):

*AllfieldsmustbecompletedinorderforWISHINtoprocessyourrequest.Allinformationonthisformremainsstrictlyconfidentialandwillbeusedsolelyforthepurposeofcarryingoutyourrequest.