NYULMC HIE Consent Form

Downtown Dermatology

Please correct the errors described below.

NYULMC HIE, CARE EVERYWHERE and HEALTHIX CONSENT FORM

Before signing the NYULMC HIE Consent Form below, please ensure that you have read the laminated NYULMC HIE Disclaimer Page
For detailed information please request for an HIE Information Sheet or call 212-404-4101.
This form has to be signed only once per practice.

PATIENT INFORMATION

NOTE: UNLESS YOU SELECTED THE "I DENY CONSENT" BOX, New York State law allows the people treating you in an emergency to get access to your medical records, including records that are available through the NYULMC HIE. IF YOU DON'T MAKE A CHOICE, the records will not be shared except in an emergency as allowed by New York State Law.

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

Your information will be encrypted.

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