• I understand that I can obtain health services by Alphabet City Medicine, P.C. (“Alphabet City”) that may include onsite, in-person physical examinations, tests, vaccinations, and prescriptions for medications by an Alphabet City physician or other healthcare personnel under such physician’s supervision.
  • I understand that I can also obtain telephonic medical consultations for refills of common prescriptions from Alphabet City through use of the Radish Health Inc. (“Radish”) technology platform. I understand that a telephonic medical consultation will not be the same as a direct patient/health care provider visit because I will not be in the same physical location as my Alphabet City Medicine care provider. I understand that the delivery of health care services through telehealth services is an evolving field and that the use of telehealth in my medical care and treatment may include uses of technology not specifically described in this consent form.
  • I understand there are potential risks to this technology, including interruptions, unauthorized access, delays in medical evaluation and treatment arising from technical difficulties and the potential inability of my health care provider to provide appropriate medical treatment for my condition via telephonic consultation. I understand that my Alphabet City Medicine care provider or I can discontinue the telephonic medical consultation if it is felt that the use of telephonic consultations are not adequate for the situation.
  • I understand that my Alphabet City Medicine care provider may determine in his or her sole discretion that my condition is not suitable for treatment using the telephonic medical consultation, and that I may need to seek medical care and treatment from an alternative source.
  • I understand that while the medical services, including use of telephonic medical consultations may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed.
  • I understand that in the event of an emergency, I should not contact Alphabet City but should immediately call “911” and request emergency care assistance.
  • I understand that in addition to my Alphabet City Medicine care provider other Alphabet City staff members may be present during the onsite visits or telephonic medical consultations. I further understand that I will be informed of their presence, and I have a right to consent to their presence.  The Alphabet City staff will at all times maintain confidentiality of the information obtained. I understand that the same confidentiality and privacy protections that apply to my onsite health care services also apply to the telephonic consultations.
  • I agree and authorize Alphabet City to share information regarding my treatment with other individuals for treatment, payment and health care operations purposes, including scheduling and billing purposes.
  • I understand that I will be billed separately for my medical treatment and use of the Radish platform (if I receive telephonic medical consultations).
  • I understand that I may withhold or withdraw this consent at any time by providing Alphabet City with such notice. Otherwise, this consent will be considered renewed and ongoing upon each onsite visit or telemedicine consultation provided by Alphabet City and its affiliated professional entities and their health care providers.

I have had a direct conversation with my Alphabet City Medicine care provider, during which I had an opportunity to ask questions regarding my medical treatment, including physical examinations and telephonic medical consultations, as applicable. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language which I understand.

By signing this Consent to Medical and Telehealth Care, I certify that:

  • I am at least eighteen (18) years of age or older
  • I am a resident of New York State or the Commonwealth of Pennsylvania
  • I have carefully read and consent to the terms and conditions stated herein
  • I have carefully read and acknowledge the terms and conditions stated in the Notice of Privacy Practices set forth in Exhibit A below and also available at
  • I have been provided the opportunity to ask questions in regard to my medical treatment and that my questions have been satisfactorily answered


To the extent that I am under 18 years of age and do not otherwise have the legal authority to consent to receive medical treatment, I acknowledge and agree that the above consent does not apply to me. I further acknowledge and agree that Alphabet City will separately provide the appropriate consent to treatment for individuals under 18, which I agree to share with my parent/legal guardian for his/her/their review. I further acknowledge and agree that Alphabet City may schedule my appointment but will not provide any medical services to me prior to obtaining a completed consent that is signed by my parent/legal guardian.

Effective as of 12/20/2018 - updated 6/24/2021





Alphabet City Medicine, P.C. (“Company”, “us”, “our”, and “we”) is committed to obtaining, maintaining, using and disclosing your protected health information (“PHI”) in a manner that protects your privacy in providing onsite medical care and/or telephonic medical consultations for refills of common prescriptions. We urge you to read this Notice of Privacy Practices (this “Notice”), carefully in order to understand both our commitment to the privacy of your PHI and your rights.

All references to “you” or “your” refer to both you and your child, if you are a parent or legal guardian of an individual under 18 who is receiving Company Services.

We are required by law to maintain the privacy of your PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. PHI is information about you, including basic demographic information, that may identify you and that relates to your past, present or future physical or mental health condition, treatment, or payment for health services. This Notice describes how we may use and disclose your PHI to carry out treatment, payment or health care operations, and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to your PHI.

We reserve the right to amend this Notice from time to time. When material changes are made, we will promptly post the updated Notice on our website at We are required to abide by the terms of the Notice currently in effect.

I. Uses and Disclosures of Your Information

The Company may use or disclose your PHI for the following purposes:

  • Treatment. We may use or disclose PHI for purposes of providing your medical treatment. For example, we may disclose your PHI to pharmacies when ordering prescription refills on your behalf or to your primary health care practitioner.
  • Payment. We may use or disclose PHI for purposes of billing and collecting payment for our services.
  • Health Care Operations. We may use or disclose PHI to facilitate our business’s health care operations. For example, we may review your PHI internally as part of an audit to confirm quality of our services being delivered to our patients.  We may use PHI to notify you of remind you of scheduled appointments or changes in our medical services.
  • As Required by Law. We may use or disclose PHI if required to do so by federal or state law.
  • Disclosures to Your Representative and/or Individuals Involved in Your Care. We may disclose your PHI to your friends or family members who are involved in your care, including those who are responsible for paying for your care. We may also disclose PHI to your personal representative, as established under applicable law, or to an administrator or authorized individual associated with your estate.
  • Disclosures to Business Associates. We may disclose your PHI to certain of our service providers, such as Radish Health Inc., that may have access to certain of your PHI – and they will also agree to protect its confidentiality.
  • De-Identification of PHI. The Company may de-identify your PHI, meaning that we would remove all identifying features as determined by law to make it extremely unlikely that the information could identify you. De-identified information no longer qualifies as PHI, meaning that we may use and disclose it for purposes not set forth in this Notice.

The Company may also use or disclose your PHI in other ways as permitted by law. Generally, these are ways that serve the public health and/or research. Specifically:

  • We may use or disclose your PHI as needed to assist with public health and safety issues and may disclose your PHI to law enforcement officials when needed, to health oversight agencies for authorized activities, and for special government functions including national security needs.
  • We may disclose your PHI as needed to organ procurement organizations, medical examiners, and funeral directors in the event of an individual’s death.
  • We may use or disclose your PHI to address workers’ compensation claims.
  • We may use or disclose your PHI in response to a court or administrative order, or in response to a subpoena.

Uses and disclosures of PHI for purposes other than those described above, including for marketing purposes and disclosures that would constitute a sale of PHI, will not be made in the absence of a written authorization signed by you or your personal representative. Once you sign an authorization, you may revoke it by contacting us at any time unless it has already been relied upon to use or disclose PHI.

II. Your Rights Regarding Your PHI

You have the following rights with respect to your PHI:

  • You have the right to request restrictions on certain uses and disclosures of your PHI. We will consider every request to restrict uses or disclosures of your PHI and will strive to honor those that are reasonable. With respect to any requested restriction, if the Company agrees to honor it, we will document such restriction and continue to abide by it.
  • You have the right to receive confidential communications of your PHI from the Company. Specifically, you may request that we communicate with you about your PHI using a specific means, phone number, or address. The Company will accommodate reasonable requests regarding confidential communications of your PHI.
  • Subject to applicable state law, you have the right to inspect and copy your PHI. You also have the right to access and receive your PHI electronically if readily producible in such format.
  • You have the right to correct or update your PHI. If you believe that there is an error in your PHI, you may request that we update it as appropriate.
  • You have the right to receive an accounting of certain disclosures of your PHI made by the Company. Upon receipt of such request, we will provide you with a list of disclosures made by the Company in the prior six (6) years, not including certain types of disclosures such as, by way of example only, those made directly to you or pursuant to your written authorization.
  • You have the right to obtain a paper copy of this Notice upon request.

To exercise any of these rights, please send written communication to us at Alphabet City Medicine, P.C., 900 Broadway, Suite 903, New York, NY 10003.

III. Breach Notification

The Company is required by law to notify you in the event that your PHI is subject to a security breach unless we reasonably determine, after fully investigating the situation and assessing the risk presented, that there is a low probability that the privacy or security of your PHI has been compromised. You will be notified without unreasonable delay and in no event later than sixty (60) days following our discovery of the security breach. Such notification will include information about the security breach, including steps that the Company has taken to mitigate potential harm, and a contact person to whom you may address additional questions.

IV. Questions, Comments, or Complaints

If you have any questions or comments about this Notice, or if you have any complaints about the Company’s privacy practices, please contact us at Alphabet City Medicine, P.C., 900 Broadway, Suite 903, New York, NY 10003.  You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services.  The Company will not retaliate against you for filing a complaint.

Effective as of 12/20/2018 - updated 10/14/2019