Legal Consent Documents for Medical Consultations

Hayy Medical PLLC
Serving residents of Florida, Texas, Arizona, and Minnesota

1. Telemedicine Informed Consent

I understand that I am engaging in a telemedicine consultation with a licensed medical provider affiliated with Hayy Medical PLLC, a multi-state medical practice. This consultation will be conducted via secure electronic communication for the purpose of evaluating and managing my health concerns.

I understand that:

  1. Telemedicine involves the use of audio, video, or other electronic communication to provide clinical services remotely.

  2. I may be asked to share medical history, laboratory results, and other health information.

  3. I have the right to withhold or withdraw consent to telemedicine at any time, without affecting future care.

  4. My privacy is protected under HIPAA, and no sessions will be recorded without my consent.

  5. Technical failures may occur, and alternative methods may be required to complete the consultation.

By continuing, I confirm that I:

  1. Reside in one of the specific states within the USA of Hayy Medical PLLC’s operation, listed above.

  2. Understand the nature and limitations of telemedicine

  3. Consent to receive medical consultation from Hayy Medical PLLC via telehealth technology

  4. Acknowledge this service is not a substitute for emergency care

2. Consent to Medical Evaluation and Treatment

I voluntarily consent to receive medical evaluation, treatment recommendations, and follow-up care from a licensed provider affiliated with Hayy Medical PLLC, a medical practice authorized to deliver care in my state of residence (FL, TX, AZ, or MN).

I understand that:

  • My provider will use the information I provide — including symptoms, history, and data — to formulate individualized recommendations.

  • Treatment may include nutritional or lifestyle guidance, laboratory testing, and/or supplement recommendations.

  • I may accept or decline any suggested treatment or testing.

  • This consultation does not replace the care of my primary care provider and is not suitable for medical emergencies.

I confirm that all information I provide is truthful and complete to the best of my knowledge, and I consent to proceed under the care of Hayy Medical PLLC.

3. HIPAA Privacy Notice Acknowledgment

I acknowledge that I have been provided access to Hayy Medical PLLC’s Notice of Privacy Practices, which explains how my personal health information (PHI) may be used and disclosed under HIPAA.

I understand that:

  • My PHI will be protected in accordance with federal law.

  • I have the right to request a printed or electronic copy of the Privacy Notice.

  • Hayy Medical PLLC may use my information for treatment, payment, or healthcare operations, as outlined in its policy.

  • No information will be disclosed without my written authorization unless legally required or permitted.

I acknowledge and accept the privacy practices outlined by Hayy Medical PLLC.