1. I would like to*
  2. First Name*
  3. Last Name*
  4. Date of Birth*
  5. Street Address*
  6. City*
  7. State*
  8. Zip*
  9. Gender*
  10. Medical Record Number
  11. Dignity Health facilities where I have been a patient:*
  13. Phone Number*
  14. Email Address*
  15. Submit

If you have not already visited a Dignity Health facility, it will not be possible to opt you out of HIE. Please make your request after your first visit.