In this Consent Form, you may choose whether to allow Mind Body Medical Services, P.C. (d/b/a Caraway Medical Services) (“Caraway Medical Services”, “we”, “us”, or “our”) to obtain access to your medical records, and whether to allow us to share your medical records with your other health care providers through the health information exchange (“HIE”) platforms listed here for the purposes described in the fact sheet. These HIE platforms can help collect the medical records you have in different places where you receive health care services and make them available electronically and securely to the providers treating you, with the aim of improving the quality of the health care services you receive.
If you consent to share your information through HIE platforms by signing below, you are giving your permission:
- For employees, agents, and members of the medical staff of Caraway Medical Services and its affiliated entities to see and obtain access to your electronic health records from your other health care providers that are authorized to disclose information through the HIE platforms
- For us to share electronic health records with your other health care providers
YOUR CHOICE TO GIVE OR TO DENY CONSENT MAY NOT BE THE BASIS FOR DENIAL OF HEALTH SERVICES OR HEALTH INSURANCE COVERAGE. PLEASE CAREFULLY READ THE INFORMATION ON THE FACT SHEET, WHICH IS PART OF THIS CONSENT FORM, BEFORE MAKING YOUR DECISION.
YOUR CONSENT CHOICES. Please select from the options below. You can change your decision in the future by emailing us at firstname.lastname@example.org or submitting a new selection. You have the following choices:
- I GIVE CONSENT to all providers, employees, agents, and staff members of Caraway Medical Services and its affiliates to access all of my electronic health information made available through HIE platforms in connection with providing health care services to me and any other permitted purposes described in the fact sheet. I ALSO GIVE CONSENT to Caraway Medical Services to share my medical records with HIE platforms in accordance with the permitted purposes described in the fact sheet.
- I DENY CONSENT to all providers, employees, agents, and staff members of Caraway Medical Services and its affiliates who would otherwise require my consent to access or share my electronic health information through HIE platforms for any purpose, including in a medical emergency.
NOTE: UNLESS YOU CHOOSE “I DENY CONSENT”, certain state laws allow the people treating you in a medical emergency to get access to your medical records, including records that are in the HIE platforms described here.
IF YOU DO NOT MAKE A CHOICE, your records will not be shared or accessed except in a medical emergency as allowed by applicable state law.
EFFECTIVE PERIOD: This Consent Form will remain in effect until the day you change your consent choice, your death, or such time as the applicable HIE ceases operation. If consent is signed by a parent or legal guardian of a minor, the consent decision will expire on the 18th birthday when the minor becomes an adult, and the patient will have to file a new consent decision. If an HIE merges with another HIE, your consent choices will remain effective with the newly merged entity.
HIE Fact Sheet
Details about electronic health information exchanged (accessed or shared) through the health information exchange (“HIE”) platforms listed here and the consent process:
- How Your Information May Be Used. Your electronic health information will be used by the organizations, providers, or programs set forth above only to:
- Provide you with medical treatment and related services
- Check whether you have health insurance and what it covers
- Conduct care management activities to assist you in obtaining appropriate medical care, improving the quality of services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical care
- Evaluate and improve the quality of medical care provided to all patients
- NOTE: The choice you make in the HIE 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.
- What Types of Information About You Are Included. If you give consent, the HIEs listed here may access ALL of your electronic health information available in your electronic medical records of participating organizations, and all employees, agents, and members of Caraway Medical Services and affiliated entities may access ALL of your electronic health information available through all of the HIEs described above. This includes information created before and after the date of the HIE Consent Form. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This information may relate to health conditions, including, but not limited to:
- Alcohol or drug use history or treatment
- Birth control and abortion (family planning)
- Genetic (inherited) diseases or tests
- HIV/AIDS diagnosis
- Mental health conditions
- Sexually transmitted diseases
- Medication and dosages
- Diagnostic information
- Lab tests
- Where Health Information About You Comes From. Information about you comes from providers or plans that have provided you with medical care or health insurance, respectively. These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, the Medicaid program, and other health organizations that exchange health information electronically.
- Who May Access Information About You if You Give Consent. Only doctors, employees, trainees, students, volunteers, and agents of the organizations you have given consent to access your health information, including our affiliate entities and us, to carry out permitted activities described in this Fact Sheet.
- Public Health and Organ Procurement Organization Access. Federal, state, or local public health agencies and certain organ procurement organizations are authorized by law to access health information without a patient’s consent for certain public health and organ transplant purposes. These entities may access your information through the HIEs for these purposes without regard to whether you give consent, deny consent, or do not fill out a consent form.
- Improper Access to or Use of Your Information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, you can contact our Privacy Team at email@example.com.
- Copy of Form. You are entitled to get a copy of the HIE Consent Form at any time.
- Retention of Records. Organizations, including any providers that participate in the HIEs listed here, that access your health information because you consented on the Consent Form, while your consent is in effect, may save, copy, or include your information in their own medical records. Even if you later decide to withdraw your consent, they are NOT required to return your information or remove it from their records.
Health Information Exchanges
Please see below for a list of HIEs Caraway may work with. Please note HIE interactions for a given patient depend on each patient’s specific care coordination needs. This list is not exhaustive.
Updated: July 2022
- Various community and enterprise HIEs participating in the California Association of Health Insurance Exchanges (CAHIE). A full list of participating exchanges may be found on the CAHIE site.
- eHealth Exchange
- Epic Systems' Care Everywhere network
- HIEs that participate in the Statewide Health Information Network for New York (SHIN-NY)
- Bronx RHIO
- Rochester RHIO
- NC HealthConnex