RHIO

Provider

Patient Name*

Email Address*

Date of Birth*

Patient Identification Number

Address*

Consent Choice* (select one)

I GIVE CONSENT for above-named Provider Organization to access ALL of my electronic health information through Rochester RHIO to provide health care services (including emergency care). I DENY CONSENT for above-named Provider Organization to access my electronic health information through Rochester RHIO for any purpose, even in a medical emergency (except for minor patients).

Print Full Legal Name*

By entering your full legal name, you are signing this agreement electronically. You agree you are the patient or the patient's legal representative, authorized to sign on the patient's behalf. Your electronic signature is the legal equivalent of your manual signature on this agreement. By selecting a consent choice above you consent to be legally bound by this agreement's terms and conditions.

Relationship to Patient*

Rochester RHIO Consent Form

Thank you for your submission!