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formerly PatientPing
Opt-Out of Patient Information Sharing
Opt-Out of Patient Information Sharing for Pings, Stories, Route, and Spotlights.
Opt-Out Form
Review and Submit
All fields are required
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Required information
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First Name
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Last Name
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Date Of Birth
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Gender
Male
Female
Non-binary
Other
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SSN - Last Four Digits
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Zip Code of Residence
*
Email
Select the facility that you are requesting to stop sharing your health information
*
Opt-Out Facility
*
Patient Medical Record Number (MRN)
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