I give consent to retrieve and use my medication history from SureScripts.

The New York State Immunization Information System (NYSIIS) is a confidential, computerized system that contains immunization records and allows authorized users access to a person's shot records. Strict federal and state laws protect the privacy of your personal information in the system. The benefits of participating in NYSIIS include:

• Your health care provider can use NYSIIS to be sure that you receive the needed immunizations, and proper medical treatment is received when needed.
• There will be a permanent and easily accessible record for your immunizations.

Participation in NYSIIS for people 19 years of age and older is voluntary, so your consent is needed. If you want to participate, please carefully read the consent below and sign in the space provided. FOr additional information about this consent, please call (518) 473-4437.

I give my consent for SOUTHTOWNS FAMLIY PRACTICE PC to release my immunization(s) and identifying information to the New York State Immunization Information System (NYSIIS). I understand the purpose of NYSIIS is to assist in my medical care and record the immunizations that I have had or will receive in the future. My immunization information may potentially be used by the Department of Health for quality improvement purposes, epidemiologic research, and disease control purposes. Information used for quality improvement or any research purposes will have my personal identifying information removed.

The immunization information in NYSIIS may be released to the following: myself, my health maintenance organization, the state and local health departments, the school that I am registered to attend, and authorized medical providers that deliver my medical care.

I understand there will be no effect on my treatment, payment, or enrollment for benefits if I choose not to enroll in NYSIIS. This consent may be withdrawn at any time by using the form provided. Information about immunizations received by NYSIIS with my consent will remain in NYSIIS if I later choose to withdraw my consent. However, future immunizations will not be recorded by NYSIIS.

I give consent for SOUTHTOWNS FAMILY PRACTICE PC to export and import my medical records through Carequality Community Chart. Carequality provides a strategy, process, and mechanisms that will support trusted, secure, interoperable exchange of healthcare information across geographies, vendor affinities, and existing information network relationships using different data sharing networks including primary care providers and specialists.