Zus Request to Opt Out 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 wish to opt out of participation in Zus, you may do so by filling out the form below.

Zus Request to Opt Out Form

I understand that:
Opting out of health information sharing through Zus may create risks, including the possibility that my treating providers may not have up-to-date information about my health needs, which may negatively impact the care I receive and which may increase the risk of unnecessary costs for duplicate tests or procedures.

Once Zus has processed my Request to Opt Out form, my health information will not be shared except as noted in the Patient Notice.

Opting out will not prevent my healthcare provider from sharing my health information with other treating providers by phone, fax or mail if requested.

Even after opting out, my healthcare provider may still share my health information through secure email, electronic medical record, or other electronic information systems not connected to Zus.

My request to opt-out will be effective five (5) to seven (7) business days after Zus receives my request.

Any of my health information which has been shared through Zus before my request to opt-out is effective will remain with the organizations which received it.

I may choose to participate in Zus again at any time by submitting to Zus a Request to Opt In Form.

Required Information

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

• Given name: __________
• Family name: __________
• Date of birth: __________
• Address line 1: __________
• City: __________
• State: __________
• Zip code: __________
• 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: Q3257
  This code is to verify you are a human.

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