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

By completing this form, I certify that I have been notified of the benefits of participating in CommonWell and of my right to opt out of having my data shared between participating health care providers through the CommonWell. I also understand that opting out of CommonWell will not affect my ability to access medical care, and my personal health information may still be shared with authorized entities and used in certain circumstances pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and state law.

Charleston Area Medical Center may not share any of my health information with CommonWell.

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-out form, please use the link below for a printable form.

Printable form