Opt-OUT Request Form 2025

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The document is an Opt-OUT Request Form for patients of Decatur Memorial Hospital Health Systems, allowing them to prevent their healthcare records from being shared through the allcharts™ system. It outlines the process for opting out, the implications of this decision on record sharing with other healthcare providers, and requires personal information and a signature to be processed.

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Click ‘Get Form’ to open the Opt-OUT Request Form in our editor.
Begin by entering your name in the designated field labeled 'Your Name'. This is essential for identifying your request.
Initial the acknowledgment statements provided. This confirms your understanding of the implications of opting out, including that your health information will not be shared through allcharts™.
Fill in the patient details: First Name, Middle Name, Last Name, and Date of Birth. Ensure accuracy as this information is crucial for processing your request.
Provide a contact phone number where you can be reached for verification purposes. This ensures that any discrepancies can be resolved quickly.
Complete your mailing address, including City, State, and Zip Code. This is necessary for any correspondence regarding your request.
If known, enter the name of your primary physician in the appropriate field.
Sign and date the form at the bottom. If someone else is signing on your behalf, ensure they print their name and specify their relationship to you.
Finally, mail the completed form to Decatur Memorial Hospital at the address provided on the form to ensure it reaches Medical Records - CIHIE.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is opt out services legitimate?

The election of a consumer to opt out must be effective for a period of at least five years (the opt-out period) beginning when the consumers opt-out election is received and implemented, unless the consumer subsequently revokes the opt-out in writing or, if the consumer agrees, electronically.

What does opt out mean?

: to choose not to participate in something.

What is an example of opt out?

Opt-out example Not choosing to subscribe to newsletters, unticking a previously ticked checkbox, not consenting to save personal details, rejecting the use of cookies, etc. are some examples of opt-out. E.g. Companies add an unsubscribe link at the end of their emails to let users opt out of emails.

Does opt out mean cancel?

To opt out of something simply means to withdraw your consent to it or to stop taking part in it. For instance, when you unsubscribe from an email marketing newsletter, you let the company that was sending you the newsletters until now that you no longer wish to receive them.

How do I opt out of tenant screening?

IS OPT-OUT PRE-SCREEN SAFE? Yes! The Opt-Out Pre-Screen was required by the U.S. Congress under the Fair Credit Reporting Act and is managed jointly by the major credit bureaus (Equifax, Experian, Innovis, and TransUnion).

What is an opt out request?

To opt out means making a deliberate choice to say no to something. In the context of data privacy, this denotes a situation where consumers withdraw their consent to certain data-driven activities (such as data sharing, targeted advertising, etc.).

Opt-OUT Request Form 2025

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