Health Information Sharing Preferences Survey
Please indicate your preferences regarding the sharing of your health information. Your responses will help us respect your choices and maintain your privacy.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
What types of health information are you comfortable sharing?
*
General health status
Medical history
Current medications
Allergies
Immunization records
Other
Who are you comfortable sharing your health information with?
*
Primary care physician
Specialists
Family members
Insurance providers
Other
For what purposes can your health information be shared?
*
Medical treatment
Insurance claims
Research (anonymized)
Family notification in emergencies
Other
How long do you permit your health information to be shared for these purposes?
*
One-time only
Until revoked by me
For a specific period
Other
Please provide any additional comments or specific instructions regarding your health information sharing preferences.
Submit Preferences
Should be Empty: