The form you have filled out authorizes Patient X to add your information to their monitoring system to enable live monitoring of any accidents to yourself that result in your arrival at a participating hospital in the state of Florida.

This live monitoring will signicantly increase the speed to deliver proper treatment and accuracy of information contained in your medical records information after an accident.

If an accident occurs and have visited your local hospital for the emergency room then you will be contacted by our PatientX for the purposes of receiving treatment for your injuries.

Patients have the right to request a copy of their health information that is available through Health Current, Florida's health information exchange (HIE). Patients also have a right to request a list of the persons who have accessed their health information through the HIE in the last three years.

If you want to request any of this information you will need to request the patient record from your PatientX representative. You will receive a response to the request within 30 days. Please note, Patient X may only send data to an address within the United States of America or its territories. If you are filling out this form for another person, the references to “I” and “my” in this form refer to that other person.