Patient Opt-Out

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

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 KONZA Request to Opt-In Form.
If there are any questions in the processing of your request, a KONZA representative will contact you using the telephone number you provided below.
 
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