Informed Consent Form (In-Person and Telehealth Services)

 

Welcome to Rizvi Brain Institute (“us,” “we,” “our,” and “RBI”).  We are a family-run clinic of expert healthcare professionals dedicated to reversing cognitive decline and helping people attain optimal cognitive performance. By merging medical expertise with principles of holistic wellness, RBI creates complete and personalized treatment plans for individuals concerned with their cognitive health. Our innovative, multi-faceted approach focuses on improving overall psychological well-being while addressing the five core domains of cognition, including attention/focus, memory, language, professing speed, and executive function.

This document contains important information about both the in-person and telehealth services we offer and our policies and procedures related to those services, privacy, and consultation. Please read this information carefully and discuss any questions you have with your clinician. Your signature below indicates that you have reviewed this information, and consent to participate in services as described.

In-Person and Telehealth Services Provided

RBI has combined decades of medical expertise in neurology, integrative nutrition, and internal medicine with proven holistic methods to create an innovative approach to improving overall cognitive health. We offer a range of services, including but not limited to accessing professional care providers for consultations, communication, assessments, and treatment by RBI providers. Depending on the service and/or patient's needs, these services may be provided in person and/or via telehealth, as described below.

Nature and Anticipated Course of Services

Consultations at RBI typically include the following: (a) A 15-Minute getting acquainted consultation during which you and your provider will make an initial determination about whether or not our services are a good fit for you; (b) If we decide to proceed after the getting acquainted consultation, we will hold a 120-Minute initial consultation; (c) After that, your provider may recommend, and you may choose to receive, any of the services or follow-up appointments based 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 generally 60 minutes long and are recommended every four weeks. Please note that these services may be offered through in-person consultations or telehealth consultations, depending on your preference and circumstances.

Throughout our work together and the delivery of the services, the RBI provider will offer a variety of professional recommendations. These may include facilitating self-awareness, encouraging new insights, experimenting with new behaviors, and exploring new perspectives on your health. It's important to note that change often involves letting go of familiar things to make room for new possibilities. Additionally, changes made in one area of your life may have an impact on other areas, such as your relationships with others.

Please keep in mind that there are no guarantees regarding your specific experience, the results you will achieve, or how you will feel during and after our work together.

Privacy of Information and Confidentiality

It is RBI's policy to respect your personal privacy and handle your information as confidentially as possible, in accordance with the law and our professional ethical standards. We do not release information to anyone outside of RBI, including the fact that you have received care, without your written permission. The exceptions to this rule are the following circumstances: under a court order; as required by law (for instance, in the case of reports of child abuse or circumstances that reasonably indicate a patient intends to carry out a threat or act of imminent, serious physical violence against themselves or another); in emergent life-threatening situations; in the case of emergent hospitalization; and when consultation with other, non-RBI, treatment providers is warranted. If you have any specific questions about our policies on confidentiality, please feel free to discuss them with your provider.

Contacting your Provider and Scheduling Appointments

Should you need to reach your RBI provider between appointments, please contact us between 9:00 am - 5:00 pm (PST) via email at [email protected]. We will do our best to respond to you within 24 to 48 hours on weekdays. Telehealth and in-person appointments can be scheduled through our confidential online portal via our website. Please come prepared to start and end your appointments on time. If you need to reschedule or cancel an appointment, you will need to do so at least 24 hours in advance of your scheduled time by sending an e-mail to us at [email protected]. 

If you do not contact us at least 24 hours in advance, this will be considered a missed appointment. If you miss or cancel a scheduled telehealth or in-person appointment, you will forfeit the appointment and will not be able to reschedule, unless you notify us at least 24 hours in advance by e-mail at [email protected].

If you arrive late for your telehealth or in-person 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.

Professional Fees

Fees for our services are as follows: (a) Getting Started: 120 minute appointment for Initial consultation, lab and/or imaging review if applicable - $1,000.00; (b) Follow-up appointments (typically every four weeks) 60 minutes each appointment $500.00 per hour; or (c) One-time payment for all services (6 appointments, four weeks apart each) $3,000.00. Payment must be made prior to starting services. For the initial consultation and follow-up appointments, and other services, payment is due prior to the appointment. Please note that chargebacks are not permitted and that by reviewing and agreeing to this patient consent, you are agreeing that you will make payment in full.

Refunds

No refunds are available, in full or in part, for any consultations, appointments or services that have already been held or completed.

Late Payments

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 invoice amount. 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, which will be included in the claim.  In the case of collections, typically, the information released to the bill collector is the patient’s name, the nature of services provided, and the amount due. We hope resorting to the 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.

Emergencies

You understand that if you have an emergency health issue, you should call your local emergency medical number or take other action as is deemed necessary.

Voluntary Participation & Informed Consent

The consultations, services, appointments, and treatments you may receive, either in-person and/or via telehealth, have both benefits and risks, and it is important for you to be fully informed. On one hand, the application of recommendations can lead to positive outcomes such as reduced distress, improved well-being, and healthier relationships. On the other hand, as we address areas of struggle, it is possible to experience uncomfortable emotions like sadness, guilt, anger, frustration, loneliness, or helplessness. Your provider will provide you with detailed information regarding the benefits, risks, and alternatives associated with specific treatment methods.

By choosing to participate in our services, you acknowledge that you are doing so voluntarily and understand that inherent risks may be present. You have been informed about the potential benefits and possible side effects of the services, and you agree to assume the risks associated with receiving services from RBI. Your agreement to this patient consent indicates that you are requesting and consenting to the services willingly, fully understanding the potential risks involved.

Accurate Medical Information

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

Miscellaneous

Your RBI provider, after evaluating your medical condition, may determine, at their sole discretion, whether it is medically appropriate to diagnose and/or treat your condition through in-person or telehealth services. By continuing to use our services, you agree with your provider's medical assessment and give consent to receive a diagnosis and/or treatment accordingly.

Please note that your provider may also determine, at their sole discretion, that your condition is not suitable for treatment via in-person or telehealth services. In such cases, they may recommend that you seek medical care and treatment from a specialist or another healthcare provider outside of RBI.

Termination of Relationship

You have the right to terminate the services at any time, whether through in-person or telehealth sessions. If you or RBI determine that the services are no longer beneficial or a good fit, either party may choose to discontinue our working relationship. We will make reasonable efforts to provide you with advance notice electronically at the email address you have provided in the event that we decide to terminate our work together.

Information Regarding In-Person Services

The following information applies specifically to in-person services at RBI. By singing your name on the signature page below, you confirm that you have reviewed this information and provide consent to participate in the in-person services as described.

1. RBI offers both in-person and telehealth services. However, please note that at times RBI may need to suspend its in-person services due to various reasons, such as increased risks posed by COVID-19 or other health concerns. In such cases, RBI may offer telehealth services as an alternative. If you have any concerns about telehealth, please discuss them with your RBI provider. Decisions regarding the availability of in-person services are made prioritizing the well-being of our community. You will be notified in advance if there are any changes in our operating protocol based on public health guidance. If you prefer telehealth services for safety reasons, RBI will strive to accommodate your preference when it is clinically appropriate and available.
2. RBI has implemented measures to reduce the risk of COVID-19 transmission within the office. Detailed information about these efforts is available on our website and in the office. If you have any questions, feel free to ask. Please note that individuals should assess and monitor their own health and safety before participating in in-person services.
3. To receive services in person, you agree to comply with all RBI policies and CDC guidelines regarding healthy behaviors and minimizing COVID-19 transmission. Failure to adhere to these safeguards may result in the requirement to engage in telehealth treatment. If you arrive for an appointment and exhibit symptoms of illness or have been exposed to COVID-19 according to RBI staff's assessment, you may be asked to leave the office immediately and seek treatment elsewhere. RBI will follow up with telehealth services as appropriate.

If RBI determines that your care provider cannot meet in person due to increased risks posed by COVID-19, alternative arrangements such as telehealth will be discussed and arranged for your continued care.

1. In the event that you test positive for COVID-19 or another highly contagious disease, RBI may be legally obligated to notify local public health authorities. However, we will only provide the minimum necessary information for data collection and will not disclose specific details about the purpose of your visits. This same rule applies if your RBI provider tests positive.

Please sign your name on the signature page below to acknowledge that you have read and understood the above information regarding in-person services at RBI.

Information Regarding Telehealth Services

This section pertains specifically to telehealth services provided by RBI. By signing your name on the signature page below, you acknowledge your consent to receive telehealth services, including consultations, assessments, treatments, and communication, through remote communication technology. You understand that telehealth services may involve education, goal setting, referral to resources, problem-solving, skills training, and decision-making support. Telehealth consultations will primarily occur via video teleconferencing or other appropriate remote communication technology. In the event of technical difficulties during a telehealth consult, your RBI provider may contact you by phone.  

In addition, you agree to the following terms related to telehealth services:

1. You have the right to withhold or withdraw consent to telehealth services at any time. If consent is withheld or withdrawn, you may request a referral to a local health provider.
2. You have the right to access records created by RBI pertaining to telehealth services, subject to any applicable fees or written authorizations.
3. Your provider will inform you if they believe that telehealth services are contraindicated for your specific condition.
4. You understand that RBI providers must be licensed in the state where you are physically located during the telehealth session, as required by state laws. You agree to confirm your location with your provider at the start of each session.
5. The confidentiality of your personal information during telehealth sessions is protected by state laws. You agree to ensure privacy by conducting telehealth consultations in a private setting, unless exigent circumstances exist. If you engage in telehealth services in a public or semi-public setting, you understand the responsibility for any personal information that may be overheard by individuals nearby.
6. You acknowledge the risks and consequences associated with telehealth services, including potential disruptions or distortions of personal information transmission, unauthorized access to personal information, and the limitations of telehealth compared to face-to-face services. If your provider deems that you would benefit from another form of intervention, you may be referred to an appropriate mental health provider.
7. In case of emergencies or crises, audio/video/computer-based services may be inappropriate. You are advised to contact 911 or Public Safety in such situations. Please provide a contact person on this informed consent form who can be reached if your clinician believes your safety is at risk

For questions, complaints, or suggestions, please contact RBI via email at [email protected]

By signing below, you acknowledge that you have thoroughly reviewed and understood all the information in this document, including RBI's policies and procedures regarding both in-person and telehealth services, privacy, and consultation. You also acknowledge and accept the risks outlined in this document. Your signature indicates your acceptance of these terms and your agreement to abide by them during your participation in RBI's healthcare services, whether provided in-person or through telehealth.

 

Name and Signature: _________________________

Date: _________________________

Phone: _________________________

Address at current location: _________________________

 

Emergency Contact at current location:

Name: _________________________

Phone: _________________________