Opt Out of Electronic Transmittal of Protected Health Information

Complete and submit this form to opt out of having your Protected Health Information (PHI) transmitted electronically outside of the Main Line Health System.

First Name Last Name Date of Birth Phone Number (If needed for verification purposes only) Address 1 Address 2 City State Zip Code

I am requesting Main Line Health and its entities not electronically transmit my health information outside of Main Line Health. I am aware that certain health care providers and their billing companies need electronic access to my PHI for Permitted Purposes (see Notice of Privacy Practices).

Please note that if you opt out of HIE by submitting this form, your PHI may still be electronically transmitted to your referring or ordering physician and to your PCP.

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Opt Out of Electronic Transmittal of Protected Health Information