Health Information Exchange (HIE) Consent
Consent to Use and Disclose Health Information Via Health Information Exchanges and Consent to Use and Disclose Sensitive Health Information
Last Updated: June 3, 2026
Overview
As used in this form, “Vida” means Vida Health, Inc. and its affiliated professional entities, Vida Medical, PC, a California professional corporation; Vida Medical, P.A., a Kansas professional association; Vida Medical, New Jersey, P.C., a New Jersey professional corporation; and Vida Medical P.A., a Delaware professional corporation (collectively, “Vida”). In this form, you can choose to provide two kinds of consents:
- Consent to Use and Disclose Health Information via HIEs: To allow Vida to share and access your medical records and other health data with and from health information exchanges (HIEs) so Vida 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 Vida to use and share certain other sensitive information with various recipients, including but not limited to through HIEs, for purposes described in this form and consistent with applicable law.
It is your choice whether to provide any of these consents. Vida’s use and disclosure of health information is intended to be consistent with its Notice of Privacy Practices and applicable law. Vida cannot condition treatment on whether you give the consents described in this form. You 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. Consent to include your other sensitive information in the health information used and disclosed by Vida, including through HIEs, will expire one year from the day that this form is completed unless earlier revoked by you.
You may revoke or change the permissions granted in this form at any time by sending written notification to compliance@vida.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 Vida has already taken or information that Vida has already used or disclosed by relying on this form.
In addition to revoking or changing consent to share or access your health information through HIEs, you may also opt out of allowing the HIEs that Vida 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 Vida’s Notice of Privacy Practices.
Health Information Exchange (HIE) Consent
By providing your consent, you give Vida, located at 20500 Belshaw Ave, DPT# EXCA1377, Carson, CA 90746-3506, 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 help your treating provider have 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, Vida will share and access your information through HIEs. Without your consent, Vida cannot request important health related information about you from other providers participating in HIEs and cannot share information with those providers through HIEs to make sure the care these providers are giving you is as informed as possible.
By providing your consent, you allow Vida to access and share your electronic health information with the recipients described below. This includes health information created before and after the date you or your representative provide this consent. 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 Result
- 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 change your consent choice.
Consent to Use and Disclose Other Sensitive Information
By providing your consent, you allow Vida to use and disclose the sensitive health information listed below, including but not limited to through HIEs. This sensitive health information will only be used and disclosed for the same purposes and to the same recipients as Vida uses and discloses your general health information. 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 expires one year from the date it is first completed, unless earlier revoked by you.