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How to opt out of Cal INDEX

Participation in Cal INDEX is completely free and voluntary. To opt out of Cal INDEX, complete and submit the information below, call (888) 510-7142, or download, print and mail the form from here.

What it means to opt out of Cal INDEX

By opting out of Cal INDEX, you are choosing not to have your personal health information accessible by your healthcare team and your health plan through the Cal INDEX system.

What to expect after you opt out of Cal INDEX

The Cal INDEX system is expected to go live by the end of 2014. Prior to go live you will receive an email confirmation that your opt-out request has been processed. (If the information you provide when opting out changes before you receive confirmation, please resubmit your request). Once your opt-out is confirmed, you can opt back in to Cal INDEX, but this capability will not be available until early 2015.

I am filling out the form for myself
I am filling out this form for someone else
First Name*
3 of 40 max characters
Middle Name
0 of 40 max characters
Last Name*
0 of 40 max characters

Date of Birth*
Previous First Name
0 of 40 max characters
Previous Last Name (for example maiden name)
0 of 40 max characters
Street Address or PO Box*
0 of 50 max characters
Apartment, Suite, or other
0 of 50 max characters
0 of 30 max characters
ZIP code*
Member of Health Plan?*

Enter Email Confirm Email
Main phone number*
Alternate phone number
You may only elect to opt-out of Cal INDEX for yourself and other individuals you are authorized by law to act on behalf of, such as a minor child, other legal dependent, or someone who has given you their health care power of attorney. Cal INDEX reserves the right to require you to submit proof of your authority when acting on behalf of another person. Individuals submitting false information may be subject to prosecution or liability for civil claims for fraud or misrepresentation.
Please review your information before clicking the submit button or if you wish to leave this page without submitting your information click cancel to exit and return to the home page


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