Patient-Facing Materials – Workgroup Request

1. Patient-Facing Materials – Workgroup Request • MAeHC • Wellport patient consent form • Wellport patient consent withdrawal form • Wellport Website: http://www.wellport.org/index.php • Rhode Island • CurrentCareRI patient enrollment form • CurrentCareRI Website: http://currentcareri.com/matriarch/default.asp • New York • Model RHIO level 1 single provider consent form • Model RHIO level 1 multi-provider consent form • Level 1 payer consent form (for quality improvement or care management activities) • Level 2 payer consent form (for payment) • Consumer Advisory Council-created • "Filling Out the RHIO Consent Form - Things to Think About" patient piece • E-health brochure for patients (general) • eHealth4NY Website: http://www.ehealth4ny.org/index.html • Maine • HealthInfoNet patient opt-out form • HealthInfoNet website: http://www.hinfonet.org/index.html • Nebraska • NeHII patient brochure/opt-out form • NeHII stand-alone patient opt-out/revoke opt-out form • NeHII website: http://www.nehii.org/ For discussion purposes only - Not for distribution

2. MAeHC (WELLPORT Pilot) Consent Form For discussion purposes only - Not for distribution

3. MAeHC (WELLPORT Pilot) Withdrawal Form For discussion purposes only - Not for distribution

4. Vermont – Patient Consent Form *Note the VT consent form is not yet final.

5. Vermont – Patient Consent Form *Note the VT consent form is not yet final.

6. New York – Model Single Provider Consent Form For discussion purposes only - Not for distribution

7. New York – Model Multi-Provider Consent Form* For discussion purposes only - Not for distribution *Page 2 (same as single provider form) removed to allow pages 1 and 3 to fit on slide.

8. Maine - HealthInfoNet patient opt-out form For discussion purposes only - Not for distribution

9. Nebraska – Patient Opt-Out/Revoke Opt-Out For discussion purposes only - Not for distribution