טופס Application to Opt Out of the National Health In ation Exchange Network for a Legally Unfit Person להורדה, הדפסה ומילוי מקוון

Form Name: Application Form to Opt Out of the National Health Information Exchange Network for a Legally Unfit Person

Summary:
The "Application Form to Opt Out of the National Health Information Exchange Network for a Legally Unfit Person" is a document used to request the removal of a legally unfit person's medical information from the National Health Information Exchange Network in Israel. This form allows the guardian of the legally unfit person to choose whether their medical information should be accessible to treatment providers through the network or not.

Required Sections:
1. Applicant's Declaration: This section includes the applicant's personal information, such as their name, ID number, gender, date of birth, and address. It also includes information about the person for whom they are the guardian for health matters.

In this section, the applicant declares the following:
a. They have read and understood the information sheet provided.
b. The National Health Information Exchange Network's purpose and functioning.
c. The consequences of opting out, which means that medical information will not be accessible to treatment providers through the network.
d. The responsibility to provide the necessary medical history and information to treatment providers.
e. The impossibility of partial removal of information or selective opt-out.
f. Continuation of sending summaries of emergency room visits or hospitalizations to the insuring HMO even after opting out.
g. The request to remove the legally unfit person from the network.

2. Request Details: This section outlines the process and administrative details, including:
a. The option to change one's mind by signing an application for reinstatement.
b. The timeline for the removal of the legally unfit person from the network.
c. The requirement to resubmit the request when transferring between HMOs.

3. Guardian's Name and Signature: This section captures the guardian's name, signature, and date of signing.

4. Signature Verification: This section is for a witness or authorized personnel to verify the identity of the applicant and the guardian and confirm that they have received the necessary information and signed the form in their presence.

Overall, this form serves as a formal request for opting out of the National Health Information Exchange Network for a legally unfit person and outlines the responsibilities and implications of such a decision.