Instructions for Provider

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Instructions for Physician Office

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Acknowledgement of Notice of
Privacy Practices – English

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Acknowledgement of Notice of
Privacy Practices – Spanish

OPT-OUT Form

This form is to be used by patients who do not wish to participate in Rio Grande Valley Health Information Exchange (RGV HIE).

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RGV HIE OPT-Out Request
Form English

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RGV HIE Opt-Out Request Form
Spanish RGV HIE Solicitud de
Exclusión Voluntaria

Want to Reapply and OPT-back into the HIE

Even if you choose to opt-out of the HIE now, you may change your mind at any time and opt back in to the exchange by downloading the
Opt-In form here and either giving it to your Provider or mailing it to 1816 East Harrison Ave. Ste. A, Harlingen, Texas 78550.

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RGV HIE Revocation Opt-Out
Form English

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RGV HIE Opt Out Form Revocation
Spanish RGV HIE Solicitud de
Anulación de Exclusión Voluntaria

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