LANES Opt-In / Opt-Out Authorization Form

Purpose of This Form

Your health care providers participate in LANES (Los Angeles Network for Enhanced Services), a secure electronic system that allows doctors, hospitals, and other health care organizations to share your medical information for your care. By signing this form, you give permission for your health information to be shared through LANES with other authorized providers.

Patient Information

Add Patient Name

Your Choices

YES, I agree (opt-in) — I allow my health information to be shared through LANES. NO, I do not agree (opt-out) — I do not want my information shared through LANES.

Signature

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

Parent/Guardian/Patient Signature:

Date:

Print Name of Representative:

Relationship to Patient:

Your information will be encrypted.