Opt-Out Form

Miners’ Colfax Medical Center (MCMC) participates in the CommonWell health information exchange (HIE) which is a secure internet based health record exchange that enables patient information to be shared electronically with physicians and other health care professionals/facilities involved in your health care.

opt-out check box

The goal of the HIE is to help health care professionals provide better, more efficient and coordinated patient care by providing access to a patient’s most recent health information that may be available from other health care professionals who are also participating in the HIE.

You may opt out of the HIE by downloading the form in your preferred format and mailing this form to our Compliance/HIPAA Privacy Officer. The address is at the top of the form.

PDF version

Word version

If you have any issues or concerns regarding this form, feel free to contact MCMC at 575-445-3661.