Health Information Exchange Consent

HEALTH INFORMATION EXCHANGE CONSENT
Fraser is requesting your permission to provide a clinical summary of information about you/your child's clinical information to external providers, as well as query other providers for their clinical summary document, called a Continuity of Care Document, or CCD.

The summary contains a core data set of the most relevant demographic and clinical information facts about you/your child's healthcare.

Fraser will not receive or release CCD queries without a signed consent. The directions below will direct you to opt in or opt out to the consent type that meets your needs.

If opting in, please identify only medical providers.
Language (other language options forthcoming):*

English
Chart Content - choose the option below based on the sensitivity of your/your child's therapy at Fraser. This enables Fraser to direct Health Information Exchange queries accordingly.

Contains information about me/my child's therapyIncludes a higher level of sensitive information about me/my child's therapy related to substance use disorder diagnosis or substance use disorder treatment records.
Please answer the following question to identify the level of sensitivity of your/your child's health information. This will guide you to the correct signature form. My/my child's current health information may contain information related to substance use disorder diagnosis or substance use disorder treatment records.*

NoYes
Should be Empty:

HEALTH INFORMATION EXCHANGE CONSENT