Date: ___________________

I, _________ (name of the patient) _____________, was diagnosed by Aaron Padron,

PMHNP-BC, on _____________________ with _____________ (diagnosis) _________________.

On ________ (date seen) _______________, I was seen by ______ (name of provider)

_______________________, a DEA-registered practitioner in ______ (name of State) ______,
with DEA Registration/License No. ____________________, in-person and in accordance with
the Ryan Haight Act, Controlled Substances Act, and the pertinent issuances and regulations
issued by the Drug Enforcement Agency (DEA).

______ (name of provider) ________, understands that _______ (name of patient)

__________ prefers Aaron Padron, PMHNP-BC, to continue managing the psychiatric care of
________ (name of patient) ________, for their psychiatric conditions.

I recognize that Aaron Padron, PMHNP-BC, as a practitioner, performed an adequate

examination of the patient in compliance with the applicable Federal and State Laws and the
relevant rules and regulations issued by the DEA. The psychiatric evaluation was conducted ine
manner consistent with his scope of practice and the prevailing professional standard of practice
for a health care professional who provides in-person health care services to patients in this
state. Any prescription that he will issue after a telehealth visit is for a legitimate medical
purpose and in the usual course of his professional practice.

The patient was also informed about the role of the telemedicine practitioner at the
distant site, as well as medical professionals at the originating site

I also hereby give my full consent to undergo telemedicine consultation with Aaron
Padron, PMHNP-BC, including: a) Store-and-forward technology; b) Remote patient monitoring
(RPM); and c) Interpretive services. I recognize that it is being conducted using an audio-visual,
real-time, two-way interactive communication system, using the following:

1. A camera that can be manually or remotely adjusted to provide multiple views of the
patient. It must also include capabilities to zoom, focus, and alter resolution, according
to the consultation requirements;s
2. A sufficient size display monitor that can accommodate for diagnostic needs in the
rendered telehealth service;
3. Bandwidth speed and image resolution that provides the necessary minimum quality to
meet a minimum of 15 frames per second;
4. Audio equipment that enables clear communication and includes noise cancellation; and
5. Technology that creates audio transmission with a 300-millisecond delay, at most.

__________________________________

(Signature and Name of the patient)

CONFORMITY:

__________________________________

(Signature and Name of the provider)