Zus Request to Opt In Form - Zus Health

About Zus

Your healthcare provider participates in the Zus Network to share electronic health information for purposes of coordinating and providing safe, convenient, integrated care to you through the Zus Platform, specifically the Zus Aggregated Profile or “ZAP”. You can learn about how Zus works, what Zus does to protect your privacy, and more by reading the Zus Patient Notice.

Instructions

If you previously opted out of participation in Zus and now desire to so participate, you may do so by filling out the form on the right.

Zus Request to Opt In Form

I understand that:

• Once Zus has processed my Request to Opt In form, my health information will be shared through the Zus Platform.
• My hospital or healthcare provider may continue to share my health information with other treating providers by mail, phone, fax, secure email, electronic medical record, or other electronic information systems.
• My request to opt in will be effective five (5) to seven (7) business days after Zus receives my request.
• I may choose to opt out of participation in Zus again at any time by submitting to Zus a Request to Opt Out Form.

Required Information

You must provide all required information in order for Zus to process your Request to Opt In Form. Zus will apply all privacy and security protections to your information as required by HIPAA and other applicable law.

• Name:
• Date of birth:
• Address:
• Phone:
• Signature:
  By checking this box, I verify that (1) I am the person named above, or I am legally authorized to complete this form for the person named above and (2) that information provided on this form, and the preferences expressed herein, are accurate to the best of my abilities.
• Type this code: 0VUZK:
  This code is to verify you are a human. Protected by xfanatical.