Opt-Out Form
This form is to be used by patients who do not wish to participate in the Health Information Exchange (HIE)

The Wyoming Frontier Health Information (WYFI) Data Exchange allows you to permit your health information to be shared by participating medical groups, hospitals, labs, radiology centers, and other health care providers through secure, electronic means. The purpose of WYFI Data Exchange is to give each of your participating providers the benefit of having access to your health information that is maintained by the participating providers when providing healthcare to you. Your participation in the HIE is voluntary and subject to your right to opt‐out. Your receipt of treatment or health plan coverage for treatment will not be conditioned on whether you choose to exercise this
right.

Unless you opt‐out, any authorized healthcare provider who participates in WYFI Data Exchange, or is a member of a health information exchange that is connected to WYFI Data Exchange, can electronically access and share your health information through WYFI Data Exchange as set forth below.

 The health information that will be shared through WYFI Data Exchange will include health information from both before and after today’s date and may include information related to treatment you received from any provider who is connected, either directly or indirectly, to WYFI Data Exchange, including out‐of‐ state providers.

 The health information that will be shared through WYFI Data Exchange includes information about your diagnoses, test results (like x‐rays or laboratory), and medications that have been prescribed to you.

 The health information that is made available to WYFI Data Exchange may be used by WYFI Data Exchange participants for treatment purposes. WYFI Data Exchange may further use your health information and make it available to other health information exchanges and their participants, for treatment, payment, and health care operations activities; however, such disclosures by WYFI Data Exchange to another health information exchange will only be permitted in accordance with applicable law and information that is disclosed will not include mental/behavioral health records, and genetic/hereditary test results.

By signing this form, I hereby ACKNOWLEDGE and AGREE as follows:

1. I am requesting that none of my health information be shared through WYFI Data Exchange. This will include in emergency care situations. If I previously consented to allow my health information to be shared through the WYFI Data Exchange, my signing this Opt‐Out form will revoke that consent and no information from WYFI Data Exchange participants will be included in the WYFI Data Exchange.

2. This Opt‐Out request only applies to the sharing of health information through the WYFI Data Exchange, and my health care providers may have access to my health information using other methods, such as by fax, telephone, email, or mail. I understand that the WYFI Data Exchange is unable to process opt-out requests for other HIE’s in which my health care providers participate.

3. I may choose to opt back into the WYFI Data Exchange at any time so that my health information may be shared through the WYFI Data Exchange. To opt back into the WYFI Data Exchange, I must submit a completed “WYFI Data Exchange Revocation of Opt‐Out Request Form” to the address provided after clicking submit.

4. I understand that any information that was shared through WYFI Data Exchange before the date this form is processed may remain with the providers who accessed such information.

5. I understand that regardless of my opt-out status, trip reports generated by an Emergency Medical Service provider will be transmitted to the healthcare facility receiving the transfer of care of a patient. This transmission is required by law. EMS Rules and Regulation, Chapter 4, Section 4(b).

6. It may take between 2 ‐ 5 business days after receipt to process this Opt‐out form and to prevent the sharing of my health information through WYFI Data Exchange.
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First Name *
Middle Initial
Last Name *
Email
Primary Phone Number *
Secondary Phone Number
Date of Birth *
MM
/
DD
/
YYYY
Sex
Male
Female
Other/ I do not wish to disclose
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Reason for Opting Out - mark all that apply *
Required
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This form was created inside of State of Wyoming.