Home › Home › Patient Forms › MHiE Consent

MHiE Information Exchange Consent

Please review the consent below and sign to authorize sharing your health information with MHiE Exchange Members.

Memorial Hermann Information Exchange “MHiE”

Patient Consent for the Use and Disclosure of Health Information

Purpose: The MHiE is a health information exchange network developed by Memorial Hermann Health System. Exchange Members include hospitals, physicians and other healthcare providers. Exchange Members are able to share electronically medical and other individually identifiable health information about patients for treatment, payment and healthcare operation purposes. We are an Exchange Member of the MHiE and we seek your permission to share your health information with other Exchange Members via the MHiE. By executing this form, you consent to our use and electronic disclosure of your health information to other MHiE Exchange Members for treatment, payment and healthcare operation purposes. We will not deny you treatment or care if you decline to sign this Consent, but we will not be able to electronically share your health information with your healthcare providers that participate in the MHiE as Exchange Members if you do not sign this Consent.

Instructions: If you agree to allow us to disclose your health information with other MHiE Exchange Members please complete the relevant portions of and sign this Consent.

Patient Information

Patient Name (Last, First, Middle)*

Date of Birth*

Information that will be Disclosed; Purpose of the Consent for Disclosure

I hereby consent to the disclosure of my medical, health and encounter information by any and all Memorial Hermann Health System Providers (collectively the “Provider”) to other participating providers in the MHiE (Exchange Members) who may request such information for treatment, payment or healthcare operation purposes. I understand the information to be disclosed includes medical and billing records used to make decisions about me.

I hereby specifically authorize Provider to release all types and categories of protected health information to other healthcare providers that participate in the MHiE for treatment, payment and healthcare operation purposes, [including but not limited to, your alcohol and treatment records, your drug abuse treatment records, your mental health records, and your HIV/acquired immune deficiency syndrome records, as applicable].

No Conditions

This Consent is voluntary. We will not condition your treatment on receiving this Consent. However, if you do not sign [and initial] this consent, where required, you cannot participate in the MHiE.

Effect of Granting this Consent

This Consent permits all MHiE Exchange Members to access your health information. Exchange Members of the MHiE are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Term and Revocation

This Consent will remain in effect until you revoke it. You may revoke this Consent at any time by completing the MHiE notice of revocation. The MHiE notice of revocation is available by calling 713-456-MHiE (6443). Revocation of this consent will also have no effect on your personal health information made available to Exchange Members during the time frame in which your Consent was active.

Individual’s Signature

I have had full opportunity to read and consider the contents of this Consent. I understand that, by signing this Consent, I am confirming my consent and authorization of the use and/or disclosure of my personal health information, as described herein.

You are entitled to a copy of this consent after you sign it. Include this Consent in the individual’s records.

Signature *

Draw your signature above using mouse or touch

Date: 3/25/2026