Skip to main content Skip to site navigation

Participation Forms and Options
Forms to Complete and Returning Forms

Post

Learn more about your SMC Connected Care Participation Options as well as forms to complete if you wish to opt out or opt back in to SMC Connected Care.

You are automatically enrolled in SMC Connected Care, therefore you do not need to do anything to be an SMC Connected Care participant. When you have an appointment with your care provider, your information will be securely transmitted to SMC Connected Care and will only be visible to providers of your treatment.

If you do not wish to be a participant in SMC Connected Care, you must complete an Opt Out Form. Please review the below information for further information and instruction.

Opt Out/Withdraw 

When you opt out, you are withdrawing your information from SMC Connected Care and your health providers will not have access to your health information via SMC Connected Care. Your health information will only be accessible via SMC Connected Care in the event of a medical emergency.

Complete Opt Out Form Online

Download Opt Out Form

All fields must be completed in the opt out form in order to process your request. It will take up to three business days to process your request upon receipt.

Opt Back In

If you have previously completed an opt out form, you have the option to opt back in if you change your mind and would like to participate. To opt back in, you must complete an Opt In form. 

Remember: Because you are automatically enrolled in SMC Connected Care, you do not need to complete an opt in form if you have never completed an opt out form. 

Complete Opt In Form Online

Download Opt In Form

Complete Forms

There are four option available to complete forms.

Option 1: Complete Form Online

You can complete an opt out or opt back in form online.

Option 2: Fax Completed Form

You can fax a form by completing the following steps:

1. Click on the link to download the form 

Link for Opt Out form

Link for Opt In form

2. Print the form

3. Complete all required fields

4. Fax form using the following number:

(650) 573-3626
Attn: SMC Connected Care

Option 3: Send Completed Form through US Mail

You can mail a form by completing the following steps:

1. Click on the link to download the form

Link for Opt Out form

Link for Opt In form

2. Print the form

3. Complete all required fields

4. Mail form to the following address:

Health IT – SMC Connected Care
HLT 362
225 37th Ave.
San Mateo, CA 94403

Option 4: Return to San Mateo County Clinic

You can return a completed form to and San Mateo County Health System Clinic by completing the following steps:

1. Click on the link to download the form

Link for Opt Out form

Link for Opt In form

2. Print the form

3. Complete all required fields

4. Bring the completed form to any San Mateo County Health System Clinic

Other Information

Opt Out and Opt In forms can be found at all San Mateo Health System Clinics. 

If you have further questions, please visit your preferred San Mateo Health System Clinic.  

Commands