On behalf of myself or my minor child or other patient named below, I acknowledge and consent to the statements made in this form. Changes or alterations to this form are not binding on Adapt Wellness Services (henceforth referred to as “AWS” in this form).


Consent to Health Care Services: 

I am requesting that health care services be provided to me (or my minor child or the patient named below) at AWS. I voluntarily consent to all medical treatment and health care-related services that the caregivers at AWS consider to be necessary for me (or the patient named below). These services may include diagnostic, therapeutic, imaging, and laboratory services, including HIV testing. If I want any HIV testing to be performed anonymously, I will tell my AWS caregiver. My blood may be used to perform routine quality assurance testing. I am aware that the practice of medicine is not an exact science; no guarantees have been made to me about the results of treatments or examinations. 


I understand that AWS may provide certain services by remote telehealth technology. Such telehealth services involve a health provider who is at a site remote from my location at the time of the service, and, as such, telehealth often involves the transmission of video, audio, images, and other types of data. The remote health provider will determine whether the condition being diagnosed or treated is appropriate for telehealth, and I understand that there is no guarantee of diagnosis, treatment, or prescription. Further, I understand that I may have to travel to see a health provider in-person for certain diagnosis and treatment matters.


Financial Responsibility: 

a. Subject to applicable law and the terms and conditions of any applicable contract between AWS and a third-party payer, and in consideration of all health care services rendered or about to be rendered to me (or the below-named patient), I agree to be financially responsible and obligated to pay AWS for any balance not paid under the “Assignment of Benefits/ Third Party Payers” paragraph below. 


b. Subject to applicable law and the Adapt Wellness Services Financial Policy, and in consideration of all health care services rendered or about to be rendered to me (or the below named patient), I agree to be financially responsible and obligated to pay AWS for the patient balances due.


Assignment of Benefits/Third-Party Payers: 

In consideration of all health care services rendered or about to be rendered to me (or the below-named patient), I hereby assign to AWS all right, title, and interest in and to any third-party benefits due from any and all insurance policies and/or responsible third-party payers of an amount not exceeding AWS’s regular and customary charges for the health care services rendered. I authorize such payments from applicable insurance carriers, third party payers, and other third-parties. A list of usual and customary charges is available upon request. I consent to any request for review or appeal by AWS to challenge a determination of benefits made by a third-party payer. Except as required by law, I assume responsibility for determining in advance whether the services provided are covered by insurance or other third party payer.


Patient Rights and Responsibilities: 

I have received a copy of the Adapt Wellness Services Patient Rights and Responsibilities document. I can also access this document at any time by visiting:

I also understand that I may, at any time, request a physical copy of this document by sending such a request to AWS by writing or phone. 


Uses and Disclosures of Health Information: 

I have received a copy of Adapt Wellness Services Notice of Privacy Practices. I can also access this document at any time by visiting:

I also understand that I may, at any time, request a physical copy of this document by sending such a request to AWS by writing or phone.


The Notice of Privacy Practices explains how AWS may use and disclose confidential health information that identifies me (or the below-named patient). I consent to let AWS use and disclose health information about me (or the below-named patient) as described in the Notice of Privacy Practices. In doing so I consent to the release of my (or the below-named patient’s) health information and financial account information to all third-party payers and/or their agents that are identified by AWS, its billing agents, collection agents, attorneys, consultants, and/or other agents that represent AWS or provide assistance to AWS for the purposes of securing payment from all parties who are potentially liable for payment for my (or the below named patient’s) health care, including for substance abuse, psychiatric care, or HIV, if applicable. I can revoke my consent in writing at any time except to the extent that AWS has already relied on my consent. 


I consent to receive, on the cellular phone and/or other telephone number(s) that are provided to AWS, text messages and/or telephone calls or other communications using live, artificial or prerecorded voices, automatic telephone dialing systems, or any other computer-aided technologies from AWS and its affiliates, clinical providers, and business associates, along with any billing services, collection agencies, agents, or other third parties who may act on their behalf. Such text messages and/or telephone calls may be related to any purpose, including those related to my account and/or the care rendered. I understand this consent to communications is not required to receive services from AWS or any of the other authorized callers and that data usage and other charges may apply. I may revoke this consent to these communications at any time. 


I hereby consent and grant to AWS the right and authority to photograph and/or record me, my image and voice, which could occur in connection with my diagnosis and treatment, and I agree that upon creation such images and/or recordings are owned by AWS. I understand that I have the right to request cessation of recording or filming at any time. I agree to release and forever discharge AWS, its agents, officers and employees from any and all claims arising out of or in connection with the use of these images and/or recordings including, but not limited to, any claims for invasion of privacy, right to publicity or defamation. 


Teaching Clinic: 

AWS is a teaching organization and is proud of its dedication to training the next generation of healthcare providers. Doctors, nurse practitioners, physician assistants, registered nurses and others in training may be involved in my (or the below-named patient’s) health care. Above all else, AWS respects a patient’s right to lead their own care. I understand that I have a right to request that healthcare professionals in training not be involved in my health care; in the event that I make such a request, it will be respected by AWS staff. 


Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow?up and/or education, and may include any of the following:



  • Patient medical records

  • Medical images

  • Live two-way audio and video

  • Output data from medical devices and sound and video files


Electronic systems used 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.



  • Improved access to medical care by enabling a patient to remain in his/her office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.

  • More efficient medical evaluation and management.

  • Obtaining expertise of a distant specialist.



As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:



  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);

  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;

  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;

  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or other judgment error.





  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent,

  2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment,

  3. I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction, and may receive copies of this information for a reasonable fee,

  4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. (name of Physician) has explained the alternatives to my satisfaction,

  5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

  6. I understand that it is my duty to inform (name of Physician) of electronic interactions regarding my care that I may have with other healthcare providers.

  7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

  8. I attest that I am located in the state of New York and will be present in the state of New York during all telehealth encounters with (name of Physician).



I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.


I understand a copy of this form will be available for me to print.

By completing the intake process, I hereby authorize Adapt Wellness Services and Tanvir Shagar NP in Family Health to use telemedicine in the course of my diagnosis and treatment.