Two Chairs may share your health records through secure networks called Health Information Exchanges (HIEs). Sharing can help your care team work together. This form explains what we may share, who may see it, and how you can withdraw your consent. If you sign, you allow Two Chairs to share the records listed below through HIEs. This includes mental health and substance use disorder records. We follow laws, including HIPAA, to protect your information.
What information may be shared
This consent covers information in your Two Chairs record, including:
- Mental health care, therapy, psychiatry, assessments, diagnoses, symptoms, and treatment plans
- Your progress, safety plans, medications, referrals, and care with other providers
- Substance use disorder screening, diagnoses, treatment, referrals, medications, and related care
- Your contact details, insurance, bills, appointments, and other records related to your care
- Information about suicide, self-harm, crisis care, and continous care
Who may receive it
Two Chairs may share your information with:
- Providers and health care sites that treated you before, treat you now, or may treat you later
- HIEs and other health record networks, plus providers and health plans that take part in them
- Others involved in your care, payment, or health care operations, as allowed by law
How HIE sharing works
An HIE lets approved members access health records. These members may include providers, health plans, hospitals, and emergency departments. They may use your records for care, payment, care planning, and health care operations. Once Two Chairs shares your records through an HIE, approved members may see them. Two Chairs will not share your records through an HIE for ads or marketing.You understand that once your information is made available through a health information exchange, authorized participants may access it as permitted by law and by the applicable exchange rules. Two Chairs will never share your information through an HIE for advertising or marketing purposes.
Substance use disorder records
Your records may include information about substance use disorder care. Federal or state laws may give these records added protection. You allow Two Chairs to share them for treatment, payment, and health care operations.
How to withdraw your consent
You may withdraw this consent at any time by sending your written request to compliance@twochairs.com. Once Two Chairs gets and processes your request, we will stop new sharing through the HIE. Your request will not undo sharing that took place before then. Records already shared may still be visible to approved providers.
Your choice
Signing is your choice. Two Chairs will not refuse treatment because you do not sign this consent, except where law allows it. By signing, you or your legal guardian confirm that you have read and understand this form. You agree to the sharing of your health information.