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:[email protected]
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 [email protected].
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.