BSCC HIE and Services
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Big Sky Care Connect (BSCC) is a secure health information exchange that allows your health care professionals to view your health information such as medicines, allergies, test results, health problems, prior care and treatments to help them make better decisions about your care. All patient information is encrypted and sent over a secure network. Only Participants and Authorized Users may access your information, and only for permitted purposes. Your health information is included in BSCC by default, but your participation is voluntary. If you decide to opt out, your health records will not be searchable through the BSCC. You will NOT be denied medical care if you decide to opt out. Your demographic information will remain accessible, and a treating provider will still be able to receive your lab results, radiology reports, and other information through traditional fax, mail, or other electronic communications. In an emergency situation where absence of immediate medical attention could reasonably be expected to result in placing your health in serious jeopardy, the treating provider has the ability to access your information through BSCC to assist with your treatment. You may choose to opt out of participation in the BSCC or change a prior election by completing and signing this form. The form can be turned into your provider or the form can be completed online at https://www.mtbscc.org/.
Full Legal Name
Date of Birth
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Please choose one of the following options that best fits your situation.
Please choose one...
I am the person for whom the request is being made.
I am making the request as the parent or legal guardian of a minor and that minor does not have the legal authority to consent to his/her own medical treatment.
I have been appointed by a court of proper jurisdiction to act on behalf of the individual for whom I am making the request as his/her legal guardian.
I have been formally appointed by the individual for whom I am making this request as her/his durable power of attorney for healthcare and that individual has an impairment that prevents her/him from making decisions on her/his own behalf.
Please chose one of the following options:
I request to opt-out of participating in BSCC.
I want to revoke my prior opt-out choice and fully participate in BSCC.
Name of Legal Representative (If applicable):
This field is for validation purposes and should be left unchanged.
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