CommonWell Health Alliance® services (“CommonWell”) Patient Opt-In Form

By completing and signing this form, I am allowing my health information to be accessible to my health care providers through CommonWell.

Rescind Opt-Out: I request to terminate my previous decision to opt-out; therefore, I am choosing to opt back in.

Last name

First name

Email address

Primary Phone #

Date of Birth

Last 4 of SSN

Street Address

City

State

Zip

The person submitting the form hereby certifies that he/she is acting as (check one)

SelfParentLegal GuardianOther

Please specify other relationship

Printable form

If you would prefer to print and mail your Opt-in form, please use the link below for a printable form.

Printable version