Jersey Health Connect Patient Opt-Out

Jersey Health Connect offers you a way to share your health information among participating doctors’ offices, hospitals, labs, radiology centers, and other healthcare providers through secure, electronic means. The purpose is for participating caregivers to have the benefit of the most recent information available from your other participating caregivers when taking care of you.

When you opt-out of JHC, doctors and nurses will not be able to obtain your health information through our network to use while treating you. Your physician or other treating providers will still be able to receive your lab results, radiology reports, and other data sent directly to them that they may have previously received by fax, mail, or other electronic communications. Public health reporting, where applicable, in accordance with law such as the reporting of infectious diseases to public health officials, will also occur through the JHC after you decide to opt out.

JHC Opt-Out Form

This form is to be used by patients who do not wish to participate in Jersey Health Connect. The form only needs to be completed once. If you do not live in New Jersey but still receive care in New Jersey, you may use this form to opt-out. If you wish to reverse your decision you may opt-back-in at any time by calling Jersey Health Connect at 855-624-6542.

Download and print the form (Spanish Version)

Mail your completed form to:
Jersey Health Connect
PO Box 261
Oldwick, NJ 08858

Fax your completed form to:

Downloads are in PDF format. Acrobat/Reader is required to view and download files. The Acrobat Reader can be downloaded for free here.