• New Patient Enrollment

    Dr. Jamal Rafique
  •  - -
  • In case of emergency

  • Insurance and ID

    Information
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Pharmacy

  • Practice Policies and Consent Forms

  • Privacy Policy
     

    At Myhealthsl.com, your privacy is important to us. This Privacy Policy outlines how we collect, use, disclose, and protect your personal information when you interact with our website. By using our site, you agree to the terms outlined below.

    Information We Collect – Personal Information

    We may collect personally identifiable information, including:

    First and last name
    Email address
    Mobile phone number

    Health-related information (e.g., medical history, medications), if voluntarily provided
    Disclosure: If you opt in to receive SMS updates, your phone number will be used specifically for that purpose. Otherwise, your number  may be used for voice calls only.

    Non-Personal Information

    We may collect technical and usage data, such as:

    Browser type
    IP address
    Pages visited
    Referring website
    How We Use Your Information – Your information may be used to:
    Provide requested products or services
    Respond to your inquiries
    Improve our website and offerings
    Conduct research and analysis
    Communicate updates and service-related messages

    Non-personal information may be used for any lawful purpose, including improving our services.

    Disclosure of Your Information
         

    We may share your personal information in the following cases:

     Service Providers

    We may share data with trusted third-party providers to support services like web hosting, payment processing, or email communication.

     Legal Requirements

    We may disclose your information to comply with legal obligations or in response to lawful requests such as subpoenas or court orders.

    Business Transfers

    In the event of a merger, acquisition, or asset sale, your personal information may be part of the transferred assets.

    We do not share your information with third parties for marketing purposes.


    SMS and Data Policy – Data Collection
    When you sign up for SMS updates, we collect:

    Name
    Email address
    Mailing address
    Mobile phone number

    Data may be collected via contact forms, email, rental agreements, or third-party reservation systems.

    Data Usage

    Data is used solely for sending SMS updates and service-related reminders.
    Your information is stored securely and not shared or sold.

    SMS Terms

    Message & data rates may apply.
    Message frequency varies.
    To opt-out, reply “STOP” or “UNSUBSCRIBE” via text, email, or by contacting us directly.
    To get help, text “HELP” or contact us at:
    Phone: (346) 368-2498
    Email: contact@myhealthsl.com

    We will confirm your opt-out and remove your number within 24 hours.

    Opt-In Requirement: By replying “YES,” you are giving explicit consent to receive SMS messages from JAMAL RAFIQ MD PA.

    Data Retention & Security
    We retain your personal data as long as you are subscribed to our SMS service. You may request deletion at any time.

    We implement reasonable security measures to protect your data. However, no method of transmission over the internet or electronic storage is completely secure.

    Children’s Privacy
    Our website is not intended for children under the age of 13. We do not knowingly collect personal information from anyone under 13   years old.

    Third-Party Links
    Our site may contain links to external websites. We are not responsible for their content or privacy practices. Please review their policies before submitting any personal information.

    Updates to This Privacy Policy
    We may update this policy periodically. If changes are significant, we will notify you by email (if provided) or post a notice on our website.       

     Your continued use of the website constitutes acceptance of the revised policy.

  • Powered by Jotform SignClear
  • Terms & Conditions
     

    Welcome to Myhealthsl.com. By using this website, you agree to be bound by the following terms and conditions:

    General Terms
    myhealthsl.com provides information related to health and wellness. This content is for informational purposes only and should not be considered medical advice.
    All content on Myhealthsl.com is protected by copyright and other intellectual property laws. You may not copy, reproduce, or use any content without prior written permission.
    We reserve the right to modify or terminate Myhealthsl.com at any time without notice.

    Use of the Website
    You must be at least 18 years old to use this website.
    You may not use Myhealthsl.com for any illegal, unauthorized, or harmful purposes.
    You agree to comply with all applicable laws, rules, and regulations while using this website.
    You are responsible for maintaining the confidentiality of your account and password.
    We reserve the right to terminate your account or restrict access to this website at our sole discretion, without prior notice.

    Disclaimer of Warranties
    We do not guarantee the accuracy, completeness, or timeliness of the information provided.
    We do not warrant uninterrupted access or that the site will be error-free or free of viruses or harmful components.
    We are not liable for any damage resulting from your use of the website, including direct, indirect, incidental, consequential, or punitive damages.

    Limitation of Liability

    Our liability to you for any reason will always be limited to the amount, if any, you have paid to access this website.
    We are not liable for indirect, special, incidental, or consequential damage resulting from your use of the website.


    Indemnification
    You agree to indemnify and hold harmless Myhealthsl.com and its affiliates from all claims, damages, liabilities, costs, and expenses (including legal fees) arising from your use of the website or your violation of these terms.

    Governing Law & Jurisdiction
         

    These Terms and Conditions shall be governed by the laws of the United States and the State of California. Any disputes shall be brought exclusively in the federal or state courts located in California.

    Entire Agreement
    These Terms and Conditions constitute the entire agreement between you and Myhealthsl.com, superseding all prior agreements or communications, whether oral or written.

    Text Messaging
    Consent to Receive SMS Messages By using this website, you consent to receive text messages from Jamal Rafique MD PA, operating as Sugarland Child & Adult Psychiatry, to the mobile number you have provided.

    Types of SMS Communications May Include:

    Appointment reminders
    Payment reminders
    Medication refill notices
    New patient intake forms
    Special offers or promotions
    Health and wellness tips
    Updates on services or products
    Event or seminar invitations
    Insurance information and documentation
    SMS Terms:

    Voluntary Consent
    Receiving SMS messages is voluntary. Refusal will not affect your ability to receive care or benefits.
    Message Frequency
    Messages are sent periodically based on relevance. Frequency may vary.
    Data Usage
    Standard message and data rates may apply. Contact your mobile provider for plan details.
    Opt-Out Option
    You may opt out at any time by replying “STOP” to any message.
    Privacy
    Your phone number and data will be protected in accordance with our Privacy Policy. We do not share phone numbers with third parties for marketing purposes without your consent.
     

    Privacy & Security
    Please notify us immediately if your mobile number changes. You are responsible for providing a correct, up-to-date number.
    Text messages may contain Protected Health Information (PHI) and are not encrypted. There is a risk that others with access to your phone could view your PHI.
    Use a password or screen lock to secure your mobile device.
    By consenting to SMS, you accept this risk. PHI disclosed via text may also be governed by applicable HIPAA notices.
    Help & Contact
     If you have any questions about these Terms & Conditions or require assistance, reply HELP to any text message, or contact us:

    Phone: (346) 368-2498
    Email: contact@myhealthsl.com

     

    MESSAGE AND DATA RATES MAY APPLY. Messages are recurring and frequency varies based on communication needs

  • Powered by Jotform SignClear
  • CONSENT FOR TELEHEALTH CONSULTATION

    • I understand that my health care provider wishes me to engage in a telehealth consultation.
    • My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
    • I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
    • I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
    • I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

      CONSENT TO USE TELEHEALTH

    Telehealth is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

    Telehealth is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
    Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
    The Telehealth Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
    I do not assume that my provider has access to any or all of the technical information in the Telehealth– or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by Service.
    To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

    By signing this form, I certify:

    That I have read or had this form read and/or had this form explained to me.
    That I fully understand its contents including the risks and benefits of the procedure(s).
    That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

    BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

  • Powered by Jotform SignClear
  • Intake Questionnaire

  • Medication agreement Form

  • PHQ-9

  •  
  • Powered by Jotform SignClear
  •  - -
  • Release of Information Form

    Mental Health Release of Information (ROI) Jamal Rafique, MD PA | Psychiatry Clinic Phone: 346 368 2498 Fax: 346 368 2499
  •  - -
  • I hereby authorize the release and/or exchange of confidential information between:

  •   Your Rights and Acknowledgments:

    ·  I understand I have the right to revoke this authorization in writing at any time.

    ·  I understand that a revocation is not effective to the extent that any person or entity has already relied on this authorization.

    ·  I understand that if this authorization was obtained as a condition of obtaining insurance coverage, the insurer may have a legal right to contest a claim.

    ·  I understand that my treatment, payment, enrollment, or eligibility for benefits is not conditioned on whether I sign this authorization.

    ·  I understand that information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected under federal or state

  • Powered by Jotform SignClear
  •  - -
  • Should be Empty: