Opt Out Form

If you want your caregivers to share your medical information using HealthInfoNet, no action is needed and you do not have to fill out this form. Also, you don't need to fill out this form if you’ve already opted out.

If you choose to opt-out, fill out this form or print one and mail to: 125 Presumpscot Street, Box 8, Portland, ME, 04103.

If you have questions, contact HealthInfoNet at 866-592-4352, 207-541-9250, or email us at info@hinfonet.org.

If you have already opted out and now want your caregivers to share your medical information using HealthInfoNet, you’ll need to opt-in.

I Choose Not to Participate and Opt-Out

First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip code:
Date of Birth:
Sex:
Day Phone:
E-mail:
SSN*:
(*This is optional. It will not be shared.)

By submitting this form, I understand my personal health information will be removed and unavailable to caregivers using the system, even in an emergency.

I understand I am choosing to Opt OUT of 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.