Informed Consent Form (Consent to Treatment)

You voluntarily desire to participate in the services provided by Rizvi Brain Institute (the “Practice”). In exchange for participation in these services and/or use of the property, facilities, and services, you consent to the following:

1. Services

Our Services include the following:

• Optional 15-Minute Getting Acquainted Consultation during which you and your provider will make an initial determination about whether or not we believe our services are a good fit for you.
• If we decide to proceed from there, we will hold a 120-Minute Initial Consultation.
• After that, your provider may recommend, and you may choose to receive, any of the Services or Follow Up appointments, depending on the provider’s assessment of your needs. Your provider’s Services may consist of one hour consultations, including Follow Up Appointments. Follow Up Appointments are 60 minutes in length and recommended every four weeks.

Throughout our work together and the delivery of the Services, the Practice will offer a variety of professional recommendations that will likely include facilitation of self-awareness, encouragement of new insights, experimentation with new behaviors, and new ways of looking at yourself and your health. Change usually involves letting go of things that are familiar in order to make room for new possibilities to emerge. Also, changes that you make in one area of your life may induce changes in other areas such as your relationships with others. All in all, you understand that there are no guarantees of what you will experience, the results you will achieve, or how you will feel during and after working together.

2. Voluntary Participation & Informed Consent

The Consultations, Services and Appointments that you may receive have both benefits and risks, and it is important that you are aware of both the benefits and the risks. For instance, application of recommendations may result in reduction in feelings of distress, stress, worry or fear, and may result in positive behavioral changes, greater happiness, more satisfying relationships, greater physical health, etc. At the same time, since our work together often involves discussing aspects of your health and wellness that you are currently struggling with, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and/or helplessness in the process as you share and shift these feelings. When a specific treatment plan is made, your provider will provide you with all facts necessary to form the basis of an intelligent consent, including the benefits and risks of each proposed method of treatment and alternatives.

You acknowledge that the Services will include services provided through telehealth, and you agree that telehealth is an acceptable mode of delivering health care services.  You understand that telehealth services are not the same as face-to-face services, and may not be as complete.  The inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery, and your provider may determine that you require in-person care.  In addition, there could be technical problems affecting the telehealth service, and the quality of transmitted data may affect the quality of services.  We utilize technology that meets recommended standards to protect the privacy and security of the telehealth service; however, the Practice cannot guarantee total protection against hacking or tapping into the tele-health visit by outsiders.  This risk is small, but it does exist.

You acknowledge that you are choosing to participate voluntarily in the Services and you recognize that they may contain certain inherent risks. You have discussed the potential benefits and possible side effects of Services and you agree that you expressly assume the risks of receiving Services. By agreeing to this informed consent, you agree that you voluntarily request and consent to our Services and our work together, and you understand and have been informed of the potential risks and you are voluntarily and knowingly assuming these risks. You have had an opportunity to ask questions and you agree to assume all risks during the Services in which you participate.

You also understand and agree to disclose any and all medications and supplements that you are taking, recognizing that failing to disclose them could cause potential negative reactions or unanticipated and harmful drug interactions if you implement certain recommendations that your provider might offer.

You agree to disclose information requested from you about your health, wellness, medication, supplements and other health conditions that we deem could impact our recommendations, treatment, and your health. You are affirming that you have stated all known medical conditions and answered all questions honestly and you agree to provide complete and accurate health information and notice of health changes at successive Appointments. If you suspect that you have a medical or mental health emergency, issue or concern, you agree to inform your provider and/or our staff immediately.

3. Scheduling & Appointments

Contacting Me: We try to be attentive to our clients. Should you need to reach your provider between Appointments, please contact us between 9:00 -5:00pm (PT). Our office  will do our best to respond to you within 24 to 48 hours on weekdays. On weekends and holidays, we will do our best to reply to you by the next business day. E-mails, calls or texts to me related to your Services are for quick questions and you will receive brief responses. If you want to discuss something at length, your provider may request that we wait and discuss your question at your next Appointment.

Scheduling Appointments: Appointments are scheduled through our confidential online portal called ELATION HEALTH. Please come prepared to start and end your Appointments on time.

Rescheduling: If you need to reschedule an Appointment, you need to do so at least 24 hours in advance of your scheduled time by sending an e-mail to us at [email protected] OR going through ELATION HEALTH PORTAL.

Cancelled & Missed Appointments: Our time together is important.  If you need to cancel your Appointment, you need to do so at least 24 hours in advance of your scheduled time by sending an e-mail to [email protected]. If you do not contact the Practice at least 24 hours in advance, this will be considered a missed Appointment. If you miss or cancel a scheduled Appointment, you will forfeit the appointment and will not be able to reschedule, unless you notify the Practice at least 24 hours in advance by e-mail at [email protected]

Late Appointments: If you arrive late for your Appointment, it will still end on time, and no additional time will be added to the end of your scheduled Appointment. Should you arrive late, you will still need to pay the full fee for the full Appointment, even though you will only be seen for a portion of the Appointment as you will have forfeited the time you missed due to being late.

4. Fees and Payment

Fees: Fees for the Practice’s Services are as follows:

• Getting started: 2 hour appointment -  $1,000 
• Follow up appointments (typically every four weeks): 60 minutes each appointment - $500 per hour

OR

• If you pay a ONE TIME payment for all services (6 appointments, approximately four weeks apart each) - $3000

Payment: Payment must be made prior to starting services. Payment may be made by PayPal, or credit/debit card. For the Initial Consultation and Follow-Up Appointments and other services, payment is due prior to appointment. Please note that chargebacks are not permitted and that by reviewing and agreeing to this Informed consent form, you are agreeing that you will make payment in full.

Insurance: At this time, the Practice  is not a member of any managed care/insurance provider panels or plans.

Refunds: No refunds are available, in full or in part, for any Consultations, Appointments or Services that already have been held or completed.

Late Payments & Non-Payment: If a payment is more than 3 days late past the due date on the invoice, you may be assessed a Late Fee of $25 in addition to the amount of the invoice. If your invoice has not been paid for more than 30 days and arrangements for payment have not been agreed upon, you agree in advance that we have the option of using legal means to secure the payment.  This may involve hiring a collection agency or going through small claims court.  If such legal action is necessary, you will be billed additional charges to cover the cost of time and expenses incurred by us in obtaining payment, including legal fees, and these costs will be included in the claim.  In the case of collections, typically the information that is released to the bill collector is the client’s name, the nature of services provided, and the amount due. We hope resorting to collection will not be necessary, but should that be the case, you are consenting to the release of this and any other relevant information should collections efforts become necessary.

5. Confidentiality & Disclosure

You consent to the use and disclosure of your identifiable health information and personal data for the purposes related to your Services. You have the right to request restrictions as to how your identifiable health information is used or disclosed to others. Your identifiable health information includes health information as well as your demographic information that is collected from us and/or created or received by us, another health care provider, a health plan, your employer or a health care clearinghouse. It will be used to create recommendations, protocols and other suggestions based on your needs. This identifiable health information relates to your past, present or future physical or mental health or condition and identifies you, or there is reasonable basis to believe the information may identify you.

You understand that you have the right to:

• Request a copy of your health records
• Request a correction of information that you deem incorrect in your health records
• Request that your health information not be shared with certain individuals
• Request that your health information not be used for certain purposes (e.g., research)
• Request us to send copies of your health records to whomever you wish
• Be informed as to who has read your records (for reasons other than treatment or payment)
• Specify how and where we may contact you

In general, the privacy of our communication is protected by law, and the Practice can only release information about our work to others with your written permission unless an exception applies; however, there are some situations in which we may be legally obligated to reveal some information about you, even without your consent. You understand that your confidential health information will not be disclosed to anyone else without your written consent prior to access or disclosure, except as allowable under state or federal law.

In addition, you should be aware of the following limits to confidentiality and you consent to disclosure under these circumstances:

• Your provider may find it helpful or required to consult with other medical or mental health care professionals for the purpose of gaining professional supervision, support, education, and exchange of ideas. During such consultations, we make every effort to avoid revealing your identity. The consultant in these instances will be a medical or mental health care professional who is therefore also legally bound to keep the information confidential. If you do not object, we will not tell you about these consultations unless we feel that it is important.
• To other health care providers who are providing health care to the patient for the purpose of diagnosis or treatment of the patient.
• To a health professional regulatory board, if your records are relevant to a professional regulatory board investigation.
• To the Industrial Commission, if you obtain treatment for an injury that arises out of or in the course of employment.
• Although rare and unexpected, it is possible that confidential information stored on our computer and protected by passwords and accessible legally only by your provider could be accessed illegally by others.

6. Termination of Relationship

You have the right to discontinue your Services at any time. If you or the Practice determines that you are not benefiting or that it is no longer a good fit for either of us, either of us may elect to discontinue our work together. We agree to do our best to provide reasonable advance notice to you via e-mail at the e-mail address you have already provided should we wish to terminate our work together.

7. Consent

You are confirming that you are of legal age to give consent, you have carefully read this Informed Consent Form, and you have had the opportunity to ask questions and address your concerns before agreeing to it. You are also indicating that you understand and will provide your informed consent to the issues related to the risks and benefits of the Services, and our policies related to confidentiality, fees and payment, and all other responsibilities and terms of this Agreement.



Last Updated: 03/06/2022