Opt-In

If you have previously chosen not to participate and have opted out, and now you want your caregivers to share your medical information using HealthInfoNet, you'll need to opt-in. To opt-in, fill out the form below, or contact HealthInfoNet at 866-592-4352, 207-541-9250 or info@hinfonet.org.

If you would prefer to download and print a paper opt-in form to mail or fax, click here.

I Choose to Participate and Opt-In

First Name	Middle
Last Name	Suffix
Address	City
State	Zip code
Date of Birth	Sex	Male Female
Day Phone	E-mail
SSN	(SSN is optional, and no data will be shared.)
Why are you choosing to opt-in?

By submitting this form, I understand my personal health information will be included and available to caregivers using the system.

I understand I am choosing to Opt IN to the HealthInfoNet system.

We will not share, sell, or release your information to anyone. Your email address will be used to generate a confirmation email that you may save for your records. Access to your email information is restricted to HealthInfoNet employees authorized to manage the information system used to generate electronic opt out/in confirmation email messages.

HealthInfoNet - 125 Presumpscot Street, Box 8 Portland, ME 04103
info@hinfonet.org | www.hinfonet.org | phone 207-541-9520 or 866-592-4352