For Private Telemedicine Services Without Malpractice Coverage

Patient Name: __________________________
Date of Birth: __________________________
Date of Consultation: __________________________

I, the undersigned patient, acknowledge that I have been fully informed, in clear and understandable terms, about the nature, scope, and limitations of the private medical consultation to be provided by MyDoctorOnCall.com, under the care of Dr. Raúl E. Ayala.

By signing this document, I give my express, informed, and voluntary consent to receive telemedicine services under the following conditions:

I understand that this telemedicine consultation is educational, advisory, and consultative in nature. It may include:

• Evaluation by video or phone teleconference
   
• Review and interpretation of medical studies, labs, or imaging
   
• General therapeutic suggestions and/or second medical opinions
   
• A treatment plan, only in jurisdictions where Dr. Ayala holds an active medical license
   

I understand that no in-person or invasive procedures will be performed, that controlled or experimental medications will not be prescribed, and that this service is not a replacement for urgent or emergency care.

I acknowledge that this consultation is a private, self-pay service and is not covered by any insurance plan.
I understand and accept that payment must be made directly and in advance, and that no reimbursement will be available from any insurance company.

I understand and accept that Dr. Raúl Ayala is acting solely as an independent medical consultant, retired from traditional in-office practice, and that he does not carry malpractice liability insurance for these services.

By signing this form, I acknowledge and agree that:

• This consultation does not establish a conventional physician–patient relationship and is not governed by hospital or emergency care standards.
   
• I accept the medical advice and guidance provided voluntarily and with full understanding of its limitations.
   
• I release and hold harmless Dr. Raúl Ayala and MyDoctorOnCall.com from any liability, claims, damages, or adverse outcomes — direct or indirect — arising from this consultation, except where prohibited by law.
   
• This waiver applies to all current and future consultations conducted under MyDoctorOnCall.com.
   

All information shared during the consultation will be handled in strict confidence, in compliance with international privacy standards and HIPAA regulations of the United States, where applicable.

This agreement shall be interpreted and enforced under the laws and jurisdiction of the State of Florida, United States, with both parties expressly waiving any other jurisdiction.

I declare that I have read and understood this document in its entirety, that I had the opportunity to ask questions, and that I sign it freely, voluntarily, and without coercion, being of sound mind and legal capacity.

Patient Signature: ___________________________                Date: _______________
Printed Name: _______________________________

Consulting Physician Signature: _____________
Name: Dr. Raúl E. Ayala

Florida law guarantees patients numerous rights within healthcare settings, including:

• Right to refuse treatment, except where otherwise provided by law. USF Health+10Online Sunshine+10Indian River Health+10
   
• Right to full information about diagnosis, treatment plans, alternatives, risks, and prognosis, unless providing it is medically inadvisable. Even refusal of such information must be documented. USF Health+5Online Sunshine+5The Florida Senate+5
   
• Right to know who is providing care (their name, role, qualifications) and what support services (like interpreters) are available. Wikipedia+13Online Sunshine+13The Florida Senate+13
   
• Right to understand facility rules and regulations—patients must be informed of how to conduct themselves. Verywell Health+13Online Sunshine+13Online Sunshine+13
   
• Right to express grievances to the provider, facility, or relevant state licensing body, and to know the applicable grievance procedures. Wikipedia+15Online Sunshine+15The Florida Senate+15
   
• Right to privacy, including limits on questions about firearms; providers must not harass patients over gun ownership and should respect their legal rights. Wikipedia+4Online Sunshine+4The Florida Senate+4
   
• Financial transparency: upon request, patients must receive counseling on financial resources, advance knowledge if the provider accepts Medicare assignment, a reasonable estimate of charges, and an itemized bill with explanations. AdventHealth+4Online Sunshine+4Indian River Health+4
   
• Right to treatment regardless of non-payment, especially for emergency medical conditions. AdventHealth+3Online Sunshine+3Indian River Health+3
   
• Involvement in research: patients must be informed if care is experimental and must voluntarily consent or refuse; their response must be documented. My Florida Families+9Online Sunshine+9Indian River Health+9
   
• Dignity and timely responses: patients are entitled to being treated with courtesy, dignity, privacy, and timely responsiveness to questions and needs. Florida Health Finder+2USF Health+2
   

Many healthcare providers (e.g., hospitals) also publish their own versions—often more expansive—of the Patient Bill of Rights, which include additional protections such as pain management, advance directives, confidentiality of records, visitation rights, complaint procedures, and safeguards against abuse and neglect. AdventHealth+1

• Nursing Home Residents’ Rights under Florida Statutes Chapter 400 (§ 400.022):
  Residents are granted rights including dignity, privacy, visitation, dietary accommodations, and the ability to file complaints. Civil lawsuits can be pursued to enforce these rights. nemours.org+3Wikipedia+3The Florida Senate+3
   
• Florida Mental Health Act (Baker Act, Chapter 394):
  Offers additional rights for individuals subjected to involuntary mental health examination or treatment—covering the regulation of restraints, seclusion, treatment oversight, and complaint resolution. My Florida Families+1
   
• Firearm Owners’ Privacy Act:
  Limits inquiry about firearm ownership during medical exams—physicians generally cannot ask about or record gun ownership unless it is medically relevant or necessary for safety. Wikipedia+2Online Sunshine+2
   

• You’re entitled to a summary of your rights upon admission and can request the full text of the law from your healthcare provider or facility. Sarasota Memorial Health Care System+1
   
• Hospitals and clinics usually provide a written “Patient Bill of Rights” or pamphlet, and many include additional points like advance directive policies and pain management standards. AdventHealth+1
   

AreaYour Rights / ProtectionsInformed Consent / RefusalRefuse treatment; receive full information or decline it.Provider TransparencyKnow who is treating you and available support services.PrivacyProtected privacy; limited firearm questioning.Financial MattersAccess to cost estimates, billing details, and payment counseling.Emergency CareGuaranteed care regardless of ability to pay.GrievancesFile complaints through provider or licensing agency.Research ParticipationVoluntary consent required for experimental treatments.Additional ProtectionsPain management, advance directives, confidentiality, visitation, abuse prevention (via hospital policies).Long-Term CareNursing home residents have specified rights and remedies.Mental HealthRights around restraint, seclusion, and treatment under Baker Act.