טופס Application to Opt Out of the National Health In ation Exchange Network, Over 18 Years Old להורדה, הדפסה ומילוי מקוון

Form Name: Application Form to Opt Out of the National Health Information Exchange Network, Over 18 Years Old

Summary:
This is the "Application Form to Opt Out of the National Health Information Exchange Network" for individuals over 18 years old. The form is dated Version 1.03, December 2013. Its purpose is to allow individuals to request the removal of their medical information from the National Health Information Exchange Network in Israel. By opting out, the individual's medical information will not be accessible to healthcare providers through the network, and they will need to provide their medical history directly to their healthcare providers.

Required Sections:
1. Applicant's Declaration:
- The applicant must acknowledge that they have read and understood the following:
a. The National Health Information Exchange Network's purpose, which allows medical information to be accessed by treatment providers in hospitals throughout Israel from the applicant's medical file stored in various healthcare institutions.
b. The existence of systems to protect the confidentiality of information within the network.
c. The implications of opting out, which means healthcare providers will not have access to their medical information from other organizations.
- The applicant must understand that it is their responsibility to provide their medical history and other relevant information to their healthcare providers.
- The applicant cannot opt out partially; it is an all-or-nothing choice.
- Emergency room visits and hospitalizations will still be reported to the insuring HMO even if they opt out.
- The applicant requests to be removed from the network despite understanding the implications.
- If the applicant wishes to rejoin the network in the future, they will need to sign a reinstatement application form.
- Removal from the network will occur within 30 days of submitting the application to the HMO or "mikol halev" call center.
- Upon transferring between HMOs or being discharged from the standing army, the applicant will need to resubmit the request to opt out at the new HMO for administrative reasons.

2. Signature Verification:
- This section involves verifying the identity of the applicant and their intention to opt out of the network.
- The verifier confirms that the applicant presented an identity document, received information about the network, and signed the form in their presence.

Overall, the form allows individuals to make an informed choice about their participation in the National Health Information Exchange Network and provides a mechanism for opting out if they wish to do so.