Consent to Use Health Information

Last updated: May 20, 2025

At Cercanos, we understand that information about your health and the care you receive is deeply personal. We are committed to protecting that information while ensuring we can deliver safe, effective, and coordinated care. In order to provide our services, we need your consent to use and disclose your health information as permitted by law.

By agreeing to this consent, you authorize JDE Medical P.A., Contigo Care Management, LLC, and their affiliates and partners (collectively, "Cercanos"), as well as trusted third parties working on Cercanos' behalf, to use, disclose, and/or release your health information, including Highly Confidential Information (defined below), for purposes of treatment, payment, health care operations, or other permitted uses under applicable law.

This may include sharing your information with:

• Your primary care provider or treating clinician
• Health plans, employers, or payors for verification of benefits and payment
• Care coordination or case management partners
• Technology vendors or subcontractors with whom we have appropriate privacy safeguards in place

We may also disclose your health information to your employer's designee if the services we provide are connected to a workers' compensation claim.

Highly Confidential Information

Highly Confidential Information includes, but is not limited to:

1. (a) substance use disorder treatment,
2. (b) genetic testing or information,
3. (c) mental health diagnoses or developmental disabilities,
4. (d) psychiatric treatment,
5. (e) HIV/AIDS testing, status, or care,
6. (f) communicable or bloodborne diseases,
7. (g) sexually transmitted diseases,
8. (h) child or domestic abuse or neglect,
9. (i) abuse of vulnerable adults,
10. (j) sexual assault,
11. (k) maternity care (including records related to newborns),
12. (l) infertility or assisted reproductive care (e.g., IVF), and
13. (m) any other protected category under state or federal privacy laws.

HIV/AIDS Authorization

You specifically authorize Cercanos to disclose any HIV/AIDS-related testing, diagnosis, or treatment (regardless of the result) to:

1. (a) third-party vendors and subcontractors who assist in providing our services, and who have entered into agreements to protect your information, for purposes such as care coordination, technology support, and payment processing; and
2. (b) your health plan, solely for care delivery and health care operations.

Patient Status

Cercanos provides care exclusively to adult patients. References to "you" and "your" throughout this form refer solely to the adult patient receiving services from Cercanos.