HEALTHIX CONSENT WITHDRAWAL FORM

Withdrawal of Consent for Participating Provider Organization – Karen Horney Clinic

I have previously signed a Consent Form allowing Karen Horney Clinic to access my electronic health information through the health information exchange organization called Healthix.

I understand that by withdrawing my Consent, Karen Horney Clinic will no longer be able to access electronic health information about me through Healthix.

If I sign this Withdrawal of Consent as the Patient’s Legal Representative, I understand that all references in this form to “me” or “my” refer to the Patient.

1. This Withdrawal of Consent will not affect the exchange of electronic health information made while my Consent was in effect.
   This Withdrawal of Consent only applies to Karen Horney Clinic and is not applicable to any Consent given to another Participating Provider in Healthix.
2. It may take several days to process my Withdrawal of Consent.
3. No Participating Provider will deny me medical care and my insurance eligibility will not be affected based on my Withdrawal of Consent.
4. I understand that if I wish to reinstate Consent for Karen Horney Clinic to access my electronic health through Healthix, I may do so by signing and completing a new Healthix Consent Form and submitting it to your Participating Provider.
5. I understand I will get a copy of this Withdrawal of Consent after I sign it.

Name of Patient *

Patient's Date of Birth *

Signature of Patient or Legal Representative

Date / Time

Date

Time

Name of Legal Guardian (if applicable)

Relationship of Legal Guardian

Submit