Get Hixny Consent Withdrawal Form - Cdphp

Withdrawing your consent for CDPHP to access your medical information through Hixny is a straightforward process. This guide provides you with the necessary steps to complete the Hixny Consent Withdrawal Form online, ensuring that you clearly understand each part of the form and its implications.

Follow the steps to complete the online form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by reviewing the first statement of the form, which indicates that you previously granted CDPHP access to your medical information and that you are now withdrawing this consent. This sets the context for your request.
3. In the second section, you need to choose between two options regarding emergency access to your medical information. Select one of the below boxes: 'I wish my medical information to be available to CDPHP in case of emergency' or 'I do not wish my medical information to be available to CDPHP, even in case of emergency.' Your choice will determine the level of access CDPHP has in emergencies.
4. The third section informs you that withdrawing your consent does not reverse any exchanges made while your consent was still valid. This means that your past medical information sharing remains unaffected.
5. In the fourth section, you acknowledge that your withdrawal only applies to CDPHP. Any consent you gave to other Hixny Participants remains in effect until you directly contact them to withdraw.
6. The fifth section indicates that it may take a few days to process your withdrawal of consent, which is standard procedure.
7. In the sixth section, you acknowledge that CDPHP cannot deny you medical care based on your decision to withdraw consent, nor can it affect your health insurance eligibility.
8. Next, fill in the required personal information including your name, CDPHP member ID number, date of birth, and the signature of either yourself or your representative if needed. Also include the date of signing.
9. If you are signing on behalf of someone else, be sure to include the printed name of the representative and their relationship to the patient.
10. Finally, after reviewing all the information provided, you can save your changes, download, print, or share the form as necessary.

Complete your Hixny Consent Withdrawal Form online to ensure your medical information is managed according to your preferences.