Health Information Exchange Opt-Out Form

This form is for individuals who DO NOT wish to participate in the Arkansas State Health Alliance for Records Exchange (SHARE) through HARK or who wish to revoke an earlier decision.

This form allows you to limit the electronic access by Arkansas State Health Alliance for Records Exchange (SHARE) of your information maintained by Hark. SHARE, part of the Arkansas Department of Health, is an electronic health information exchange that your healthcare treating providers use to share health care information about you in order to provide higher quality and better coordinated care. Because social determinants of health can greatly impact the healthcare and outcomes of an individual, Hark has elected to participate with SHARE to make certain limited information about Hark users available to SHARE for access by the individual’s treating healthcare provider. As a result, your information provided to or maintained by Hark will be available electronically to your treating providers unless you decide to opt-out and not have your information shared electronically.

If you opt-out, your treating providers will not be able to access through SHARE the information you provided to Hark . You have the option to change your mind and terminate your opt out decision. You may request a copy of this form. If you sign as a legal representative, all references to “you” in this form refer to the patient.

BY SELECTING THE “REQUEST TO OPT-OUT” BOX BELOW, HARK WILL NOT SHARE YOUR INFORMATION WITH SHARE; HOWEVER, ANY INFORMATION SHARED BY HARK PRIOR TO THE DATE ON THIS OPT-OUT FORM MAY ALREADY HAVE BEEN VIEWED OR ACCESSED BY YOUR HEALTHCARE PROVIDERS. FURTHER, THIS OPT-OUT IS SPECIFIC TO YOUR INFORMATION HELD BY HARK. YOU WILL NEED TO CONTACT EACH OF YOUR HEALTHCARE PROVIDERS OR SHARE DIRECTLY IN ORDER TO RESTRICT ANY OTHER PARTICIPATING PROVIDERS FROM SHARING YOUR INFORMATION WITH SHARE.

INSTRUCTIONS: Check only one box and provide all requested information below. Please print, sign and date the form.