Effective Date: February 27, 2025
Consent to use and disclose health information via health information exchanges & consent to use and disclose sensitive health information.
Overview
In this form, you or your representative can choose to provide two kinds of consents:
- Consent to Use and Disclose Health Information via HIEs: To allow Thyme Care to share and access your medical records and other health data with and from health information exchanges (HIEs) so Thyme Care can support the treatment, payment, and health care operations activities of your providers, health plans or other payers, and other entities involved in your care, health, or wellness.
- Consent to Use and Disclose Other Sensitive Information: To permit Thyme Care to use and share certain other sensitive information with various recipients, including via HIEs, for purposes described in this form and consistent with applicable law.
Consent to permit Thyme Care to use and disclose your health information via HIEs and consent to include your other sensitive information in the information used and disclosed by Thyme Care are voluntary. Thyme Care’s use and disclosure of health information is intended to be consistent with Thyme Care’s Notice of Privacy Practices and applicable law. Thyme Care cannot condition treatment on whether you or your representative give the consents described in this form. You or your representative have a right to receive a copy of this form.
As noted below, consent for the use and disclosure of your general health information through HIEs will be in effect unless revoked by you or your representative. Consent to include your other sensitive information in the health information used and disclosed by Thyme Care, including through HIEs, will expire one year from the day that this form is completed unless revoked by you or your representative.
You and/or your representative may revoke or change the permissions granted in this form at any time by sending written notification to privacy@thymecare.com, and this change will be effective for future uses and disclosures of protected health information or other sensitive information, as applicable. However, any change or revocation will not be effective for actions that Thyme Care has already taken or information that Thyme Care has already used or disclosed by relying on this form.
In addition to revoking or changing Thyme Care’s permission to share or access your health information through HIEs, you may also opt out of allowing the HIEs that Thyme Care participates in from sharing your information with others. More information about your right to opt out of the sharing of your information through an HIE can be found in Thyme Care’s Notice of Privacy Practices.
Health Information Exchange (HIE) Consent
By completing this portion of the consent form, you or your authorized representative give Thyme Care, Inc., located at 10 Lea Avenue, Nashville TN, 37210, and its affiliated entities (collectively, Thyme Care) consent and permission to use and disclose your health information about you including through health information exchanges, also referred to as “HIEs.”
HIEs are networks of organizations that assist health care providers and others to exchange information for a variety of purposes, including to make sure your treating provider has all of the relevant information to make well-informed treatment recommendations. Entities participating in HIEs may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, government programs, and other organizations that share health information electronically.
With your consent, Thyme Care will share and access your information through HIEs. Without your consent, Thyme cannot request important health related information about you from other providers and cannot share information with those providers to make sure the care these providers are giving you is as informed as possible.
By completing this portion of the consent form, you or your authorized representative allow Thyme Care to use or disclose your electronic health information to the recipients described below. This includes health information created before and after the date you or your representative complete this consent form. Your health information may include a history of illnesses or injuries, test results, and a list of medicines you have taken, and other types of information including:
- Demographic Information
- Payment Records
- Physician Progress Notes
- Admission History & Physical
- Consultation Reports
- Operative/Procedure Reports
- Imaging/Radiology Reports
- Lab Test Results
- Physician Orders
- Discharge Summary
- Nursing Notes
- Billing Records
Potential recipients of your health information may include:
- Health Care Providers
- Health Plans
- Community-Based Organizations
- Social Care Services Providers
- Health Information Exchanges and their Participants
- Data Aggregators
HIEs may also further use or disclose your health information in ways required by law. For example, certain HIEs may also make health information available to Federal, state, or local public health agencies, for public health purposes consistent with applicable law.
This consent will remain in effect until the day you or your representative change your consent choice.
Consent to Use and Disclose Other Sensitive Information
By completing this portion of the consent form, you allow Thyme Care to use and disclose, including via HIEs, the sensitive health information listed below. This sensitive health information will only be used and disclosed for the same purposes and to the same recipients as Thyme Care uses and discloses your general health information. Additionally, certain kinds of sensitive health information may receive further protections under state or federal law.
This information includes:
- HIV/AIDS Test Results
- Genetic Test Results
- Substance Use Disorder Records
- Behavioral Health – Details of mental health diagnosis and/or treatment provided by a psychiatrist, psychologist, mental health clinical nurse specialist, or licensed mental health clinician (LMHC), except psychotherapy notes (The patient or patient’s representative understands that permission may not be required to release mental health records for payment purposes.)
- Sexually Transmitted Infection Test Results
- Family Planning Records
This consent will remain in effect until the day you or your representative change your consent choice. This consent expires one year from the date it is first completed.
Para ver este consentimiento en español, haga clic aquí.