Last updated: June 10, 2024
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 primary care and behavioral health 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 primary care and behavioral health treatment by various types of healthcare providers via telecommunications technology (also referred to as “telehealth”). Our Providers include physicians, nurses, and equivalent licensed professionals. In addition to primary care and behavioral health treatment, 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 using telehealth services for primary and behavioral health care, 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.
At times, your clinician may seek supervision or consultation with other Zocalo Health or non-Zocalo Health clinicians regarding your treatment. All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and your personal information will be shared or disclosed in compliance with our Privacy Policy.
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.
MEDICATION MANAGEMENT. If medication is of interest to you as part of your current care plan, the Zocalo Health providers can provide you with a virtual assessment to determine if medication is appropriate. All medication management services will be provided at the professional discretion of the Zocalo Health Provider. Medication is not guaranteed as part of the services provided.
YOUR FINANCIAL RESPONSIBILITY, 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. Some or all of the telehealth services may be covered in full by your health plan. However, you understand that your health plan may not pay the full amount of the actual bill for services, and you acknowledge and agree that you are fully responsible for paying Zocalo Health any amounts not paid by your health plan, including non-covered charges and all copayments, coinsurance, and deductibles. Payment is expected on or before the payment due date set forth in the statement or bill. You further acknowledge and agree that it is your responsibility to inquire about the costs of the telehealth services in advance when such costs are unclear to you. You agree to provide us with proof of insurance and identification upon request, including potentially before an appointment or interaction through which Zocalo Health provides telehealth services. In the event any collection action is necessary to collect amounts you owe to Zocalo Health, you agree to pay all expenses associated with such action, including but not limited to, collection agency fees and attorneys’ fees.
ASSIGNMENT OF BENEFITS; CONSENT TO RELEASE INFORMATION. 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 such amounts. 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. Without limiting the foregoing, you authorize the Zocalo Health (or third parties working on its behalf) to release to your health plan information necessary to process claims for payment for services or supplies provided to you, and you authorize direct payment to the Zocalo Health of all benefits payable to you for such services. If you claim benefits under Title XVIII of the Social Security Act (Medicare), you hereby certify that the information you provide in applying for payment of such benefits is correct and you specifically authorize Zocalo Health to release to the Centers for Medicare and Medicaid Services and its Medicare administrative contractors any information needed for this or any related Medicare claim.
You acknowledge that you understand and agree with the following
STATE REGULATIONS:
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 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.
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 understand the purposes of and resources available to you surrounding this treatment, including the right to refuse treatment, and your responsibility in choosing a provider and treatment that best suits your needs. RCW 18.19.060.
The information you share in psychotherapy is protected health information and is generally considered confidential by both Washington state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). RCW 18.19.180.
Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety. Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, is to: (A) Provide protection for public health and safety; and (B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. Clients have the right to choose counselors who best suit their needs and purposes.
A copy of the acts of unprofessional conduct in RCW 18.130.180 can be found on the Washington State Legislature’s website at this address http://apps.leg.wa.gov/RCW/default.aspx?cite=18.130.180.
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.
