Informed Consent for Treatment

Zaya Care
Last updated: September 5, 2025

It is our duty to ensure that you are fully informed about the nature of the healthcare services you will receive, enabling you to make an informed decision regarding your consent to treatment. This form serves to confirm that you have been provided with all necessary information and that you voluntarily consent to the treatment offered. Please review this document carefully before providing your acknowledgment.

1. Consent to Receive Healthcare Services

By signing this form, you voluntarily consent to receive healthcare services from licensed professionals affiliated with Zaya Care — the collective designation for the affiliated professional entities Bienetre Medical PC (New York) and Bonheur Medical PC (New Jersey), operating in affiliation with their management services organization, Zaya Care, Inc., which acts as a HIPAA Business Associate to the affiliated medical practices. Together, these entities form an Organized Health Care Arrangement (OHCA) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

These services may include, but are not limited to:

• Preventive and wellness care
  
  

• Physical or occupational therapy
  
  

• Nutrition counseling
  
  

• Rehabilitative care
  
  

• Non-invasive diagnostic or functional assessments
  
  

• Other healthcare services provided within the licensed scope of practice of your provider
  
  

You understand that Zaya Care, Inc. does not provide clinical services or make clinical decisions. All medical care and treatment decisions are made by licensed providers affiliated with the professional entities.

Your provider will explain the proposed treatment plan, including the nature, benefits, risks, and any alternatives. You are encouraged to ask questions at any time. You may decline or withdraw from treatment at your discretion, without penalty, consistent with applicable law and ethical standards.

B. Onsite Services

Zaya Care offers traditional in-person healthcare services at designated office locations. These face-to-face visits enable direct interaction with your healthcare provider, allowing for physical assessments, hands-on therapies, and in-person consultations as appropriate to your treatment plan.

In-person visits provide an opportunity for thorough evaluation and immediate feedback, fostering a comprehensive approach to your care. We take appropriate precautions to maintain a safe and hygienic environment consistent with current health guidelines and regulations.

You are encouraged to attend scheduled appointments as agreed, and notify your provider in advance if you need to reschedule or cancel. If you have any concerns related to in-person visits, including accessibility or health safety, please discuss these with your provider.

C. Telehealth Services

Zaya Care may deliver some services through telehealth, which allows you to consult with your provider using secure video or audio technology.

Benefits of telehealth include increased convenience, access to services from your home or workplace, and greater scheduling flexibility. Risks may include technological failure, communication delays, or reduced ability to conduct physical assessments.

Your provider will determine whether telehealth is appropriate for your care. You will work together to develop a backup plan in the event of technical difficulties or disconnection. It is your responsibility to keep your contact and emergency information current.

Please note: If you are experiencing a medical emergency, you must call 911 or go to the nearest emergency room. Telehealth is not appropriate for emergency care.

D. Confidentiality & HIPAA Authorization

Your health information is protected under HIPAA and relevant state laws. As part of your care, your Protected Health Information (PHI) may be shared between Zaya Care’s affiliated medical entities and Zaya Care, Inc., as permitted within the OHCA.

This means that your PHI may be accessed, used, and disclosed among the affiliated providers and administrative staff for purposes such as:

• Treatment (e.g., coordinating services between providers)
  
  

• Payment (e.g., submitting claims to insurers)
  
  

• Healthcare operations (e.g., quality improvement, auditing)
  
  

Your PHI will not be sold or shared outside of Zaya Care without your consent, unless required or permitted by law. You may request a copy of Zaya Care’s Notice of Privacy Practices, which outlines how we protect and manage your health information.

Certain exceptions to confidentiality apply. Zaya Care may be legally required to disclose your PHI in the following circumstances:

• Suspected abuse or neglect of a minor or vulnerable adult
  
  

• If you pose a serious risk of harm to yourself or others
  
  

• In response to valid court orders or legal requests
  
  

E. Medical Records

Zaya Care will maintain your health records in compliance with HIPAA and state-specific laws. Records are stored securely and retained for a minimum of six (6) years, or longer where required by law.

You have the right to request access to your medical records, amendments, or an accounting of disclosures, subject to applicable law. You also have the right to request restrictions on how your PHI is used or disclosed.

F. Financial Responsibility

You acknowledge that:

• You are financially responsible for services not covered by your insurance
  
  

• You authorize Zaya Care to release necessary PHI to third-party payors for billing purposes
  
  

• You authorize direct insurance reimbursement to Zaya Care where applicable
  
  

• Payment is due upon receipt of a bill unless otherwise agreed
  
  

Please ensure your insurance and billing information is accurate and updated prior to receiving services.

G. Your Consent and Acknowledgment

By signing or electronically acknowledging this form, you confirm that:

• You have read and understood the information in this Informed Consent form
  
  

• You consent to receive healthcare services from Zaya Care-affiliated providers
  
  

• You consent to Zaya Care, Inc. acting as a HIPAA Business Associate and managing your PHI in accordance with HIPAA regulations
  
  

• You acknowledge that Zaya Care operates as an Organized Health Care Arrangement (OHCA) and that your PHI may be shared among its entities for treatment, payment, and healthcare operations
  
  

• You understand the potential risks and benefits of both in-person and telehealth services
  
  

• You have been informed of your privacy rights under HIPAA and how your data will be handled
  
  

• You understand you may ask questions and revoke this consent at any time, subject to applicable legal and ethical limitations
  
  

If you have any questions about this form, your care, or your rights under HIPAA, please contact Zaya Care through compliance@zayacare.com before proceeding.

Acknowledgment and Signature

By signing below, I acknowledge that I have read, understand, and agree to the terms outlined in this Informed Consent for Treatment form. I consent to receive healthcare services from Zaya Care and its affiliated providers, and I authorize the use and disclosure of my Protected Health Information as described herein.

Patient Name: _________________________________________

Date of Birth: ________________________

Signature of Patient or Authorized Representative: ___________________________

Date: ________________________

If signed by Authorized Representative, please print name and relationship to patient:
 Name: _________________________________________
 Relationship: ____________________________________

Provider Name: __________________________________________

Provider Signature: ________________________________________

Date: ________________________