MODEL RHIO CONSENT FORM

HEALTH INFORMATION EXCHANGE CONSENT FORM
Tufts Medical Center
A Member of New England Quality Care Alliance, Inc.
As you may know, Tufts Medical Center (Tufts MC) is a member of a network of healthcare providers called New England Quality Care Alliance, Inc.,
(NEQCA) which is a not-for-profit organization. In this Consent Form, you are being asked to choose whether or not you will allow a subset of your
medical information from Tufts MC and your other NEQCA providers to be viewed in a secure computer network operated by Tufts MC and NEQCA
called the Tufts MC/NEQCA Health Information Exchange (HIE). This subset of information, which is further defined in the box below, could be
accessed by providers within Tufts MC and NEQCA. Tufts MC and NEQCA may also send this subset of information through any secure means,
including mail, fax, secure state-wide health information exchange known as the Massachusetts Health Information Highway (“Mass HIway”), or other
secure electronic transmission to other external providers or organizations involved in your care in order to allow your care to be coordinated more
comprehensively and seamlessly. Your Tufts MC and NEQCA providers may also request additional information from these other providers and
organizations through any secure health information exchange for your care coordination. This subset of information may also be used to check
whether you have health insurance and what it covers and to evaluate and improve the quality of medical care provided to you and other patients. The
only individuals that will have access to this subset of your clinical information are your medical care provider, providers in the Tufts MC/NEQCA
network, other external providers or organizations involved in your care, authorized personnel of these providers or organizations, NEQCA’s quality
and efficiency medical director and personnel, and others whose job it is to maintain, secure, monitor, and evaluate the operation of the Tufts
MC/NEQCA HIE. The subset of information will not include your entire medical record. It will only include summary information in the following
categories if the information exists in your medical record:
Patient demographics
Insurance information
Advance directives
Problems/diagnoses
Allergies and alerts
Medication list (includes medications prescribed by Immunizations
providers outside the Tufts MC/NEQCA network)
Family history
Social history
Vital signs
Medical test results
Procedures
Encounters
Medical equipment
Plan of care
Health care providers
The information contained in the HIE is based on standards developed by the Massachusetts Medical Society, the Healthcare Information and
Management Systems Society, the American Academy of Family Providers, and the American Academy of Pediatrics (among other organizations). It
will include sensitive information from your medical record including, but not limited to, information related to mental health conditions and treatment for
these conditions, venereal diseases/sexually transmitted diseases, abortion(s), domestic abuse, rape/sexual assault, substance (drug and alcohol)
abuse and treatment for substance abuse, genetic diseases and genetic testing and test results, mammograms, and HIV/AIDS. As part of this
Consent Form, you specifically consent to the release of this and other sensitive health information and you acknowledge that you are
waiving your legal rights under Massachusetts law to specifically authorize disclosure of this information.
You may use this Consent Form to decide whether or not to allow Tufts MC or NEQCA providers to view your medical information in the HIE. You can
give consent or deny consent, and you can change your mind at anytime by completing a new Consent Form and selecting a different option. Your
choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or
to deny consent may not be the basis for denial of health services. However, to the extent you have denied consent, you understand that
your health information will not be available to providers in the Tufts MC/NEQCA network and other providers or organizations involved in
your care and, as a result, these providers and organizations may have limits on their ability to coordinate your care.
If you check the “I GIVE CONSENT” box below, you are saying “Yes, Tufts MC and other NEQCA providers may view my information in the secure
computer network operated by NEQCA and Tufts MC, and this information may be accessed by, sent securely to, and requested from authorized
individuals, including providers within the Tufts MC/NEQCA network and other providers and organizations involved in my care, for the purposes
described in this form.
If you check the “I DENY CONSENT” box below, you are saying “No, Tufts MC and other NEQCA providers may not view my medical information
from Tufts MC in the secure computer network operated by NEQCA and Tufts MC.” If you deny consent, only basic demographic information and your
decision to deny consent will be seen in the HIE.
Please carefully read the information on the back of this form before making your decision.
Your Consent Choices. You can fill out this form now or in the future. You have two choices.

I GIVE CONSENT for Tufts MC and my other NEQCA providers to view my information in the secure computer network operated by NEQCA
and Tufts MC. Tufts MC and NEQCA may also send my information through any secure means, including mail, fax, secure state-wide health
information exchange known as the Massachusetts Health Information Highway (“Mass HIway”), or other secure electronic transmission to other
providers or organizations involved in my care, for the purposes described in this form, including for emergency care. I also consent to allow my
Tufts MC providers to request additional information from these other providers and organizations through any secure health information
exchange. Providing consent today will override any previous denial of consent.

I DENY CONSENT for Tufts MC and my other NEQCA providers to view my information in the secure computer network operated by NEQCA
and Tufts MC for any purpose, even in a medical emergency. I also deny consent for my Tufts MC providers to request additional information
from other providers and organizations involved in my care through any secure health information exchange (e.g., the MA HIway).
_________________________________________
Print Name of Patient
_________________________________________
Signature of Patient or Patient’s Legal Representative
______________________
Date
_______________________
Time
_________________________________________
Print Name of Legal Representative (if applicable)
_________________________________________________
Relationship of Legal Representative to Patient (if applicable)
Details about patient information in the Tufts MC/NEQCA HIE and the consent process:
1.
How Your Information Will be Used. Your electronic health information will be used by providers in the Tufts MC/NEQCA network, other
providers or organizations involved in your care, authorized personnel of these providers and organizations, NEQCA’s quality and efficiency
medical director and personnel, and others whose job it is to maintain, secure, monitor and evaluate the operation of the Tufts MC/NEQCA HIE
only to:
Provide you with medical treatment and related services
Check whether you have health insurance and what it covers
Evaluate and improve the quality of medical care provided to all patients
Perform administrative management of the Tufts MC/NEQCA HIE
NOTE: The choice you make in this Consent Form does NOT allow health insurers to have access to your information for the purpose of
deciding whether to give you health insurance or pay your bills.
2. What Types of Information about You Are Included. If you give consent, your Tufts MC providers, and your other NEQCA providers may view a
subset of information that was placed into the Tufts MC/NEQCA HIE by your Tufts MC and NEQCA providers. Both Tufts MC and NEQCA are not-forprofit organizations. This subset of information could also be accessed by other providers and organizations involved in your care in order to allow
your care to be coordinated more comprehensively and seamlessly. This includes information created before and after the date of this Consent
Form.This subset of information will not include your entire medical record. It will only include summary information in the following categories if the
information exists in your medical record:
Patient demographics
Insurance information
Advance directives
Problems/diagnoses
Allergies and alerts
Medication list (includes medications prescribed by
providers outside the Tufts MC/NEQCA network)
Immunizations
Family history
Social history
Vital signs
Medical test results
Procedures
Encounters
Medical equipment
Plan of care
Health care providers
As part of this Consent Form, you specifically consent to the release of sensitive health information from your medical record, including,
but not limited to, information related to mental health conditions and treatment for these conditions, venereal diseases/sexually
transmitted diseases, abortion(s), domestic abuse, rape/sexual assault, substance (drug and alcohol) abuse and treatment for substance
abuse, genetic diseases and genetic testing and test results, mammograms, and HIV/AIDS.
3.
Who May Access Information About You, If You Give Consent. Only these people may access information about you: providers in the Tufts
MC/NEQCA network, other providers or organizations involved in your care, authorized personnel of these providers or organizations, NEQCA’s
quality and efficiency medical director and personnel, and others whose job it is to maintain, secure, monitor and evaluate the operation of the
Tufts MC/NEQCA HIE.
4.
Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access to or use of your electronic health
information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, call your
provider’s practice.
5. Re-disclosure of Information. Any electronic health information about you may be re-disclosed by your medical care provider and others
authorized to access this subset of information to the extent permitted by state and federal laws and regulations. This is also true for health
information about you that exists in a paper form. If the receiver is not a health plan or health care provider, the released information may no
longer be protected by federal privacy regulations.
6.
Effective Period. This Consent Form will remain in effect until the day you withdraw your consent.
7.
Withdrawing Your Consent. You can withdraw your consent at any time by signing a new Consent Form and choosing to deny consent for your
Tufts MC providers, other NEQCA providers, and other providers involved in your care to view your information in the computer network
maintained by NEQCA and Tufts MC, and then giving this form to your Tufts MC or NEQCA Provider. By withdrawing your consent you are also
choosing to deny consent for your Tufts MC and other NEQCA providers to: (a) share your information through other secure electronic means,
including but not limited to secure state-wide health information exchange known as the Massachusetts Health Information Highway (“Mass
HIway”), and (b) request additional information from your other providers and organizations involved in your care through any secure health
information exchange. You can also agree to consent in the future by signing a new Consent Form at any time. You can get the Consent Form
from your Tufts MC or NEQCA provider’s office. You understand that denying consent will not have an effect on any actions taken prior to such
denial.
Note: Providers that are directly involved in your care and other individuals authorized by this Consent Form may access your health
information through the Tufts MC/NEQCA HIE while your consent is in effect. Providers that treat you at their Tufts MC or NEQCA
practice may copy or include your information in your record in their practice. Even if you later decide to withdraw your consent, they
are not required to return it or remove it from their records.
8. Copy of Form. You are entitled to get a copy of this Consent Form after you sign it.
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