Opt-Out Form

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*
First Middle Last
Date of Birth*
MM
DD
YYYY
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Phone Number*
Requesting Individual*
Please choose one of the following options that best fits your situation.
Consent Decisions
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.
Electronic Signature*
Date signed*
MM
DD
YYYY
Name of Legal Representative (If applicable):
Name
This field is for validation purposes and should be left unchanged.