Patient Opt-Out

The medical groups, hospitals, and other health care-related entities (Participants) who care for you and related parties who pay for such health care services share your health information through OneHealth New Jersey, a secure, electronic Health Information Exchange (HIE)* unless you Opt-Out of OneHealth New Jersey.

If you do not want your health information shared and used through the HIE, complete and submit the form below. By submitting this completed Opt-Out Form you understand and agree that:

  • Your information will not be available to Participants and it may not be available in the event of an emergency. 
  • Participants are not required to remove any health information that was shared with them through the HIE prior to the date of this form being submitted and processed.
  • It may take between 2 - 5 business days to process this Opt-Out form.
  • If you want your health information shared through the HIE in the future, you must complete and submit a OneHealth New Jersey Request to Opt-In Form.
If there are any questions in the processing of your request, a OneHealth New Jersey representative will contact you using the telephone number you provided below.
 
*OneHealth New Jersey is the Health Information Exchange endorsed by the Medical Society of New Jersey and operated by the KONZA network.
 
ALL FORMS FIELDS BELOW ARE REQUIRED UNLESS NOTED "OPTIONAL."

First Name:

 
Middle Name:


Last Name:

 
DOB:

 
Gender:


Address:

 
City:

 
State:

 
Zip:

 
 
Phone Number:

 
 
Social Security Number (Optional):

 

Patient Email (Optional):

 
Physician/Facility Name (Optional):


Physician office/Facility email (Optional):

 

I am completing this form as a legal representative of the above noted patient.


Participants Map