Crisp Consent Email

We have chosen to participate in the Chesapeake Regional lnformation System for our Patients, lnc. (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may "opt-out" and disable all access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public Health reporting and controlled Dangerous Substances information. As part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name:

Date:

Signature of Parent/Legal Guardian/Patient 18 yrs of age or older:

Date:

Our office has a new EMR (electronic medical record) system and we need the following information to qualify for our meaningful use requirements.

Race:

Asian

Black or African American

White

Hispanic

Native Hawaiian

Other Race

Other Pacific Islander

Refuse to Report

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Refuse to Report

Language:

English

Spanish

Indian (Hindi/Tamil)

Other

If "Other", please specify:

Email Address:

Your information will be encrypted.