Consent Tool

CRISP is an affiliate of CRISP Shared Services and is the designated health information exchange (HIE) in Maryland and the District of Columbia. An HIE is a way of instantly sharing health information among doctors’ offices, hospitals, labs, radiology centers, and other healthcare organizations. You can find more information about HIE and CRISP at the CRISP website www.crisphealth.org/for-patients/.

Not all SUD/MH treatment providers are sharing information with CRISP. You can ask your SUD or MH provider if they are sharing information with CRISP. CRISP signs up new providers each day, but your SUD/MH provider should tell you if they share information with CRISP. At this time, the only data CRISP gets from any SUD/MH provider is a list of their patients. We do not currently receive any clinical data (lab results, discharge summaries, etc.) but this data could be added at any time and would be shared if you select “Disclose All SUD/MH Treatment Data” on the consent form(s).

The provider consent form allows members of your healthcare team, including your hospital providers, primary care providers, and specialists to view your SUD/MH data. The SUD/MH information is only shared with healthcare providers who list you as a patient in their practice or at the hospital.

You may choose the expiration date at the bottom of the form. If you do not choose a date, it will expire one year from the date you sign the form.

You may revoke your consent at any time by asking your provider to log-on to CRISP and deactivate the       consent form.  CRISP will immediately stop sharing your SUD/MH data. This will not apply to            information that was shared while your consent was active.

If you do not submit the consent form, CRISP will not share any of your SUD/MH treatment data. We will shield your SUD/MH data and not share it with anyone. If you choose to submit a consent at a later date, we will share the SUD/MH data with your healthcare team at that time.

CRISP will NOT share any of your data with law enforcement or with the legal system. Your SUD/MH information will only be shared with your healthcare team if you submit the consent form and with no one if you do not submit the form.

Yes, you can request an accounting of disclosures from CRISP. This list of providers will include everyone who has seen any of your data in CRISP, including your SUD/MH data. You can request that list by completing the webform at https://disclosures.crisphealth.org/.

CRISP policy is that your provider may not force or require you to submit this form. You must be given a choice of whether to submit the form and what type and amount of information you wish to share with your health care providers and/or payer(s).

When you share your SUD/MH treatment information, members of your healthcare team will be aware that you are currently in SUD/MH treatment or that you have been in the past. Some patients prefer to keep this information private and only share it with specific providers. Your SUD/MH treatment information cannot be used to discriminate against you or deny you care. If you believe this has happened, please contact your SUD/MH treatment provider.

This consent form is used only for you to allow your SUD/MH treatment information to be shared through CRISP. Your SUD/MH provider may have other consent or release of information forms for you to complete to share information directly with others.

If you have questions about your SUD treatment information, please talk directly to your SUD provider. In addition, you can find more information about federal law protecting your SUD treatment information at the SAMHSA website. www.samhsa.gov.