Informed Consent for In-Person and Telehealth Health Services
Last updated: November 5, 2025.
DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY.
In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, contact the National Suicide Prevention Lifeline (call or text 988); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).
We are pleased you have chosen Center for Neurohealth, Inc., d/b/a Salma Health (“Salma Health”), for your health needs. This document is intended to inform you of what you can expect of your clinicians in terms of their credentials and in connection with your treatment via telehealth and in-person. If you are accepting this document for another person (“Family Member”) as such Family Member’s guardian, conservator, or custodian, or as parent of a minor child Family Member, you agree to the terms, conditions, and notices contained or referenced herein on behalf of such Family Member. After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must accept these terms before commencing services.
YOUR CLINICIAN’S CREDENTIALS. Your clinicians’ credentials were made available to you before scheduling an appointment. If you have any questions about these credentials, please direct them to your clinician. For those states that require it, you can find an explanation of the levels of regulation applicable to clinicians under the STATE REGULATIONS section of this document.
YOU MUST BE AT LEAST 18. In order to obtain healthcare services from Salma Health, you must be at least eighteen (18) years of age unless otherwise specifically agreed by Salma Health (in which case you will be required to agree to an additional Salma Health consent document specific to minor patients). Salma Health may ask you for identification or other information to verify your age and identity. Salma Health reserves the right to refuse to provide services to you if you are unwilling to provide such identification or information.
Please visit the Patient Bill of Rights and Our Treatment Philosophy, as updated by us from time to time, before commencing services with us. By agreeing to this document, you are attesting that you have read, understood and will comply with the Patient Bill of Rights and Our Treatment Philosophy.
IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELEHEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS. In addition to in-person services, Salma offers scheduled individual sessions and scheduled group sessions by means of telehealth. This simply means treatment by clinicians via telecommunications technology. Our clinicians include skilled and experienced Psychiatrists, Neurologists and other types of Physicians, Psychologists, Nurse Practitioners, Licensed Clinical Social Workers, Marriage and Family Therapists, and equivalent licensed professionals. They each use a collaborative treatment process wherein they work with you on identified goals for overall improvement and changes you deem important or necessary to improve the quality of your life.
Generally speaking, telehealth offers benefits such as improved access to care by enabling patients to remain in their local site (e.g., home or work) while their clinician consults and/or obtains test results at distant/other sites, efficient health evaluation and management, and the expertise of specialists that patients otherwise might not have. There are potential risks associated with telehealth, which include, but may not be limited to: it may become clear that telehealth is not an appropriate treatment format given a patient’s presenting symptoms or level of functioning, resulting in a recommendation that the patient obtain an additional in-person care; the clinician may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient; delays in medical evaluation and treatment could occur due to deficiencies or failures of telecommunications equipment; security protocols could fail, causing a breach of privacy of personal medical information; and lack of access to complete medical records, which could result in adverse drug interactions or allergic reactions or other judgment errors in rare cases.
At times, your clinician may seek supervision or consultation with other Salma Health clinicians regarding your treatment, to enhance the services being provided to you given the multiple perspectives, experiences, and treatment philosophies. All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and none of your personal information will be shared or disclosed with any other individual without your consent. Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from the client or guardian (i.e. voluntary release signed by the client or guardian); during supervisory consultations; diagnosis and dates of service shared with an insurance company to collect payments; information released as outlined in Salma Health’s Notice of Privacy Practices and Privacy Policy; and as otherwise required by law.
SCHEDULING AND CANCELLATIONS. Please carefully review the Scheduling and Cancellations Policy. By agreeing to this document, you are attesting that you have read, understood and will comply with the Scheduling and Cancellations Policy.
MEDICATION MANAGEMENT. If medication is of interest to you as part of your current care plan, the Salma Health providers can conduct a visit to determine if medication is appropriate. All medication management services will be provided at the professional discretion of the individual Salma Health provider. Medication is not guaranteed as part of the services provided.
ASSIGNMENT OF BENEFITS; FEES AND BILLING ARRANGEMENTS. Prices are subject to change. You are required to pay all fees for your services upfront at the time of service; however, you are not obligated to pay any fees for which another party (e.g., your health plan) pays on your behalf. If you believe any of the fees you have been charged are incorrect, you must immediately contact us in writing regarding the amount in question to be eligible to receive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify us in writing within thirty (30) calendar days after the charge, that you believe the charge is inaccurate (setting forth an explanation of why). If you receive payment directly from your insurance company or third-party payer, you agree to immediately forward all healthcare payments that you receive for services provided to you.
You hereby assign to Salma Health or its affiliates that furnishes your treating provider’s services to you all right, title, and interest in any and all health insurance or other health care benefits payable to you or on your behalf by any health plan, including private insurance, Medicare, Medicaid and any other health plan for medical or other professional services furnished by Salma Health. The assignment will remain in effect until revoked by you in writing. If you claim benefits under Title XVIII of the Social Security Act (Medicare), you hereby certify that the information you provide in applying for payment of such benefits is correct and you specifically authorize Salma Health to release to the Centers for Medicare and Medicaid Services and its Medicare administrative contractors any information needed for this or any related Medicare claim. Without limiting the foregoing, you also authorize Salma Health to release to your health plan information necessary to process Salma Health’s claim for payment for services provided to you. You also authorize direct payment to Salma Health of all benefits payable to you for such services.
You understand that your health insurer or other health plan may not pay the full amount of the actual bill for services. You acknowledge that you are still responsible for paying Salma Health any amounts not paid by your health plan, including non-covered charges and all copayments, coinsurance, and deductibles. You understand that if your health plan requires a referral, you are responsible for obtaining one prior to your appointment. In the event any collection action is necessary to collect amounts you owe to Salma Health, you agree to pay all expenses associated with such action, including but not limited to, collection agency fees and attorneys’ fees.
RELATIONSHIP WITH THE SERVICES ORGANIZATION. Salma Health works closely with a separate legal entity called Salma Health, Inc. and certain of Salma Health, Inc.’s subsidiaries, including Kaizen Research Center, LLC (together with their successors and assigns, collectively, the “Services Organization”). The Services Organization is a technology company under separate legal ownership from Salma Health and provides technological and administrative support to Salma Health and owns and operates the Salma Health website located at: www.salmahealth.com (together with any other websites, or other technology platforms which the Services Organization may operate from time to time, collectively, the “Platform”). Nothing in this document should be construed to indicate that the Services Organization is a healthcare provider or that the Platform itself provides medical services or medical advice.
RECORDING AND ARTIFICIAL INTELLIGENCE SUPPORT. At times, your provider may record your in-person or telehealth consultation (in whole or in part) as part of Salma Health’s care improvement and monitoring efforts. By agreeing to this document, you acknowledge and agree that your encounter may be recorded in this manner. Please reach out to us if you have any questions about this policy.
You understand and consent to Salma Health using certain augmented technologies as part of your in-person or telehealth encounters, such as ambient listening technology, that records your interactions with your provider and that Salma Health may process and record such conversations through artificial intelligence (“AI”) models and technologies so that we can better serve you (collectively, the “AI Technologies”). The information provided by the AI Technologies to Salma Health is administrative in nature and should not be considered official statements or responses from Salma Health in response to your specific situation nor do the AI Technologies provide healthcare treatment, advice or medical recommendations.
You further agree and understand that any recordings or any content produced through AI Technologies is not part of your legal medical record.
All recordings and records pertaining to your encounters will be retained and disposed of in accordance with applicable federal and state law requirements.
By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:
- You hereby consent to receiving Salma Health’s services via telehealth technologies. You understand that Salma Health and its providers offer both in-person and telehealth-based medical services, but that these services do not replace the relationship between you and your primary care doctor. As it relates to telehealth encounters, you also understand it is up to the Salma Health provider to determine whether or not your specific clinical needs are appropriate for a telehealth encounter.
- You have been given an opportunity to select a provider from Salma Health prior to the consult, including a review of the provider’s credentials.
- You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that Salma Health will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that with respect to telehealth, a telehealth encounter may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.
- You understand there is a risk of technical failures during the telehealth encounter beyond the control of Salma Health. You agree to hold harmless Salma Health for delays in evaluation or for information lost due to such technical failures.
- You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment or in-person care from us. You understand that You may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, that you will be directed to dial 9-1-1 immediately and that Salma Health providers are not able to connect you directly to any local emergency services.
- You understand that alternatives to telehealth consultation, such as in-person services are available to you from us, and in choosing to participate in a telehealth consultation, you understand that some parts of the services involving tests may be conducted by individuals at your location, or at a testing facility, at the direction of the Salma Health provider (e.g., labs or bloodwork).
- You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
- You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Salma Health provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the consultation and thus will have the right to request the following: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.
- You understand that our providers do not evaluate injuries or provide assessments for the purposes of worker’s compensation or disability claims, disputes, litigation or similar documentation purposes.
- You understand that there is no guarantee that you will be given a prescription for medication.
- You understand that if you participate in a consultation, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery.
- You have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth below:
STATE REGULATIONS.
State California
What You Should Know
You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment, or, affecting your ability to access covered services from Medi-Cal in the future. You understand that you have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth. You understand that Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. Cal. Welf. & Inst. Code Ann. § 14132.725(d)).
You understand that you have the right to refuse care from a trainee without penalty. Cal. Code Regs. Tit. 22, § 92309.
Relevant Board Contact Information
Physicians: All Salma Health physicians licensed to practice in the State of California are licensed and regulated by the Medical Board of California. To check on a physician’s license or to file a complaint, go to www.mbc.ca.gov, email licensecheck@mbc.ca.gov, call (800) 633-2322 or use this QR code:
Psychologists:
Board Of Psychology
1625 North Market Blvd., Suite N-215
Sacramento CA 95834
Telephone: (916) 574-7720
Nurse Practitioners:
Website: https://www.rn.ca.gov/
Verify a License, Permit, or Continuing Education Provider Number
Complaints may be filed:
Online: DCA BreEZe Online Services
Mail: You may complete a Complaint Form and mail to:
Board of Registered Nursing
Attn: Complaint Intake
PO Box 944210
Sacramento, CA 94244-2100
Fax: (916) 574-7693
Email: Enforcement.BRN@dca.ca.gov
LMFT, LCSW, LPCC & LEPs: California Board of Behavioral Sciences
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916) 574-7830
https://www.bbs.ca.gov/about/contact_us.html
California Open Payments Disclosure: The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here: https://openpaymentsdata.cms.gov. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
You have read this document carefully, and understand the risks and benefits of the telehealth services and in-person care and have had your questions regarding the services explained and you hereby give your informed consent to participate in a telehealth consultation under the terms described herein.
