PROVIDERS
PATIENTS
PAYORS
BSCC HIE and Services
Learn More
Conference Headquarters
FAQs
Contact
News & Events
DONATE
Help Desk
DONATE
BOARD PORTAL
Opt-Out Form
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email Address
*
Phone Number
*
Requesting Individual
*
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.
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):
Email
This field is for validation purposes and should be left unchanged.
×
Thank you!
You'll be hearing from us soon.
BACK TO SITE