Last updated: July 29, 2023
DO NOT USE THIS SERVICE IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY. In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-272-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).
We are pleased you have chosen Zocalo Health, PLLC, Zocalo Medical Group CA, P.C. (collectively, “Zocalo Health”) and their affiliated healthcare providers (“Providers”) for your telehealth needs. This document is intended to inform you of what you can expect of your Provider in terms of his or her credentials and in connection with your treatment via telehealth. After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.
YOUR TELEHEALTH PROVIDER’S CREDENTIALS. Your Provider’s credentials were made available to you before scheduling an appointment. If you have any questions about these credentials, please direct them to your telehealth Provider.
IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELEHEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS. Zocalo Health offers treatment by various types of healthcare providers via telecommunications technology (also referred to as “telehealth”). Our Providers include physicians, nurses, and equivalent licensed professionals. The services provided may also include chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. There are various benefits associated with telehealth services, including improved access to care by enabling you to remain in your home while the provider consults with you, more efficient care evaluation and management, and obtaining expertise of a specialist as appropriate. Possible risks include delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, and in rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
TREATMENT AND CONFIDENTIALITY OF MINORS. In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor. If the parents of a minor are separated, treatment is provided to the minor only with the written consent of both parents. If the parents of the minor are divorced, consent for treatment of the minor may be given by the parent authorized to make medical decisions for the minor. If a court of law has ordered that medical decisions for the minor are to be made jointly by the minor’s parents, then consent of both parents is required for treatment of the minor. In the case of minors, as defined by state law, parents may request information about their child’s diagnosis or treatment. While release of this information will be provided, it is best that the process be a collaborative one involving the minor, parent, and clinician in order to maintain the rapport established between the minor and clinician since rapport is vital to treatment success. Therefore, unless there is a safety concern, the minor would be consulted about the disclosure and encouraged to share the information with the parent first in order to establish better communications within the family structure.
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.
FEES AND BILLING ARRANGEMENTS. You are responsible for the cost of all professional fees associated with your use of our telehealth services, which may change from time to time, and the cost of any medications or supplies prescribed by your Zocalo Health Provider as well as any equipment provided by Zocalo Health, including but not limited to peripheral equipment for use in engaging with the telehealth technology.
ASSIGNMENT OF BENEFITS: You hereby authorize direct payment to Zocalo Health of all insurance and plan benefits, including Medicare, Medicaid and/or Tricare, otherwise payable to or on your (or the below-named patient’s) behalf for services rendered by Zocalo Health if you or the below-named patient) receive payment directly from your insurance company or third-party payer, you agree to immediately forward to Zocalo Health all health-care payments you (or the below-named patient) receive for services provided by Zocalo Health. You consent to any request for review or appeal by Zocalo Health its associates or agent, to challenge a determination of benefits made by your (or the below-named patient) insurance carrier or third-party payer.
You acknowledge that you understand and agree with the following:
1. You hereby consent to receiving Zocalo Health’s services via telehealth technologies. You understand that Zocalo Health and its Providers offer telehealth-based medical services, but that these services do not replace the relationship between you and your primary care doctor. You also understand it is up to Provider to determine whether or not your specific clinical needs are appropriate for a telehealth encounter and you may be directed to in-person care if the Provider deems it appropriate.
2. You have been given an opportunity to select a Zocalo Health prior to the consult, including a review of the provider’s credentials.
3. You understand that federal and state law requires healthcare providers to protect the privacy and the security of health information. You understand that the Zocalo Health will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.
4. You understand there is a risk of technical failures during the telehealth encounter beyond the control of the Zocalo Health. You agree to hold harmless Zocalo Health for delays in evaluation or for information lost due to such technical failures.
5. You acknowledge and agree that you are solely responsible for ensuring that the information that you submit through the telehealth technology is accurate, complete and current. You understand that the Provider will rely on this information to diagnose and prepare a treatment plan for your medical condition and your failure to provide accurate, complete and current information may lead to a delay in your treatment or a misdiagnosis.
6. You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, that you will be directed to dial 9-1-1 immediately and that your Provider is not able to connect you directly to any local emergency services.
7. You understand that alternatives to telehealth consultation, such as in-person services are available to you, and in choosing to participate in a telehealth consultation, you understand that some parts of the services involving tests may be conducted by individuals at your location, or at a testing facility, at the direction of the Provider (e.g., labs or blood work).
8. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
9. You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the consultation and thus will have the right to request the following: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.
10. You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.
11. You understand that if you participate in a consultation, you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery.
12. You have read and understood the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth below:
Texas: You understand that your medical records may be sent to your primary care physician. (Tex. Occ. Code Ann. § 111.005). You have been informed of the following notice:
NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.
9353, For more information, please visit our website at www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS – Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us
You have read this document carefully, understand the risks and benefits of the telehealth services and have had your questions regarding the services answered. You hereby give your informed consent to participate in a telehealth consultation under the terms described herein.