Consent to Use and Disclose Health Information

Last updated: July 4, 2022

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At Zocalo Health, we know that information about your health and the care you receive is personal, and we are committed to protecting that information. In order to use the services, we need your consent to use and disclose your health information in certain situations.

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You hereby permit and provide your express consent for Zocalo Health, PLLC and Zocalo Medical Group CA, P.C. (collectively, “Zocalo Health”) or third parties who work on behalf of Zocalo Health (including, but not limited to, Zocalo Health MSO, LLC) to use, disclose, and/or release your health information, including, without limitation, Highly Confidential Information (which is defined below), for purposes of treatment, payment, health care operations, or other permitted purposes described below, to the fullest extent permitted by applicable law. Without limiting the preceding sentence, Zocalo Health may release your health information to your primary care or treating provider and any person or entity liable for payment on your behalf in order to verify coverage or payment questions, or for any other purpose related to benefit payment. Zocalo Health may also release your health information to your employer’s designee when the services delivered are related to a claim under worker’s compensation.

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“Highly Confidential Information” means information about (a) substance use disorder treatment, (b) genetic information or test results, (c) mental health or illness or developmental or intellectual disability, (d) psychiatric treatment, (e) HIV/AIDS testing or treatment or status, (f) communicable or blood borne diseases, (g) sexually transmitted diseases, (h) child or domestic abuse and neglect, (i) abuse of an adult with a disability, (j) sexual assault, (k) maternity records (including medical records of new mothers and newborns), (l) infertility or fertility assistance, IVF, or artificial insemination, and (m) any other type of information that is given special privacy protection under state or federal laws.

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Without limiting the above, you specifically authorize Zocalo Health to disclose any HIV/AIDS-related testing, test results, status, diagnoses, or treatment information (including if an HIV test was ordered, performed, or reported, regardless of the results) (a) to certain vendors and subcontractors that help us provide services and that we have entered into an agreement with specifically for the purposes of safeguarding your health information, to facilitate your use of the app, for case management and care coordination purposes, and for payment and health care operations purposes, and (b) to your health plan for payment and health care operations purposes.

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If you are a parent or legal guardian of a minor who is receiving treatment, you agree that you are providing this consent on behalf of your minor child.  References to “you” and “your” throughout this form include the patient and, as applicable, any parent/legal guardian.