Telehealth Consent Policy

YOU UNDERSTAND THAT BY CHECKING THE “AGREE” BOX FOR THESE TERM OF USE AND/OR AMY OTHER SUCH FORM OF THE SAME PRESENTED TO YOU FROM TIME TO TIME ON THE SITE YOU ARE AGREEING TO THESE TERMS OF USE AND THAT SUCH ON-GOING ACTIONS IN USING THE SITE CONSTITUTE A LEGAL SIGNATURE AND ON-GOING AGREEMENT TO THESE TERMS OF USE (IN WHATEVER FORM).

This Telehealth Consent Policy explains how virtual neurology services are delivered by Premier Neuro Health, led by Dr. Nizar Souayah, MD, FAAN, FANA, FAANEM. By scheduling or participating in a telehealth appointment, you consent to the use of electronic communications for medical evaluation and treatment.

1. Nature of Telehealth

Telehealth involves the use of secure video and audio technology to allow a healthcare provider to deliver medical care remotely. The process may include:

• Interactive video conferencing, audio, and data transmission.
• Review of medical records, images, and diagnostic information.
• Electronic prescriptions and coordination of care.

2. Limitations of Telehealth

Telehealth has limitations, including but not limited to:

• The inability to perform certain physical examinations.
• Potential technology failures (audio, video, or data interruptions).
• Limited diagnostic scope for conditions requiring in-person evaluation.
• State licensing restrictions that prohibit care outside authorized jurisdictions.

3. Patient Rights

You have the right to:

• Withdraw consent at any time without affecting future care or insurance benefits.
• Request an in-person referral when appropriate.
• Access your medical information as permitted under HIPAA.
• Know the identity and credentials of your treating clinician.

4. Security and Confidentiality

All telehealth sessions are conducted through a HIPAA-compliant platform with encryption and access controls.

Your information will not be recorded, stored, or shared without your consent, except as required by law.

5. Risks

Despite safeguards, risks include:

• Interception or unauthorized access to communications.
• Equipment malfunction or incomplete transmission.
• Inaccurate assessment due to incomplete data or visual limitations.

6. Emergencies

Telehealth services are not appropriate for medical emergencies.

If you experience severe symptoms such as sudden weakness, loss of consciousness, chest pain, or stroke symptoms, call 911 or go to the nearest emergency department.

7. Consent and Acknowledgment

By accepting this Consent to Telehealth, you acknowledge your understanding and agreement to the following:

• You are the person who is seeking a telemedicine evaluation, and that you are accepting this Consent to Telehealth on your behalf.
• That you are at least 14 years old.
• You agree to participate in a telemedicine evaluation.
• You authorize the electronic transmission of your medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in your medical or mental health care. [Note: the likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small].
• You understand that you can withdraw your permission at any time and that you do not have to answer any questions that you consider to be inappropriate or are unwilling to have heard by other persons.
• You understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for you to see a specialist in person.
• You understand that medical records of telemedicine services will be kept with Premier Neuro Health.
• You understand that some or all of your medical information may be used for teaching or educational purposes.
• You agree to have your telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis and presentation in verbal or written format at scientific meetings).
• You understand that any presentation will not identify you by name or other identifiable markers.
• You confirm you are physically located in NJ, NY, MA, CA, FL, or -for second opinion services only- IL or SC at the time of service.

As it relates to your privacy, you understand that we are committed to gathering, accepting, using and disclosing your personal information and your personal health information professionally, responsibly, and only to the extent required in providing health related services.

You agree that you have access to our full Privacy Policy and Notice of Privacy Practices and that you may obtain a written copy of either of those documents from us if you wish. You agree that we may record your telehealth session and use the recording for lawful purposes such as training, product improvement and to evaluate the quality of services that you have received.

You agree that we may use your email address and other contact information as a means of providing you with information regarding your healthcare, including appointment reminders and account notifications.

You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consultation without affecting your right to future care or treatment. However, you understand that we are a telemedicine-only provider, and that we may not be in a position to offer you future services if you withdraw your consent.

8. Contact

Premier Neuro Health
info@premierneurohealth.com
(908) 379-3979