Patient Registration

Permission to Participate in Telehealth Consultation and Treatment

1. Purpose: The purpose of this Telehealth Permission Form is to get permission from patients to use the telehealth services during the treatment.

2. Medical Information & Records: Medical history and test details can be discussed with other healthcare professionals. The patient will be contacted via video and audio or audio only during a telehealth appointment/visit. Video, audio, or any other digital photo of the patient can be recorded during the telehealth visit for treatment purposes only. Information will be protected under HIPAA.

3. Patient Rights: The patient can withhold or withdraw the consent or permission to telehealth consultation/treatment at any time.

4. Limitations: The telehealth appointment/visit will be similar to the regular office or in-clinic visit. Because this service uses videoconference technology, the visit may not be equivalent to or adequate as the regular in-clinic visit. The patient may be recommended a visit physically after the telehealth visit by his or her healthcare provider for certain services. Telehealth has limitations compared to in-person consultations, including the potential for technical issues.

I have been informed about the potential limitations, benefits of the telehealth practices and confidentiality of personal and medical information, and records. The opportunity to ask questions had been given to me and they were answered completely. I have understood the information and I have given my permission to participate in Telehealth Consultation.

Each patient must have a unique email address to create their personal scheduling portal account. Please enter the email you would like to use as your login. If you are registering multiple patients, ensure that each patient is registered separately and has a distinct email address to access the scheduling portal.

Note: for patients receiving all or some of their diagnostic assessment virtually, we might need to ship some materials to your home.

During the scheduling process your intake and initial exam will likely be conducted online via our telehealth assessment program. Whereas, testing appointments are scheduled based on availability. This can be either online or in-clinic.

In-clinic visits are assigned to the closest clinic in NJ based on your zip code. For patients who live too far from our New Jersey clinics, your testing will be conducted online using our neurodiagnostic interactive testing platform.

Please review and sign and date the NCBI’s NCBI's Financial Policy by clicking the following link and once the financial responsibility party signs you will be directed back to this registration form.

Other indicators from 2-5 years of age

Please review all the information entered and correct any mistakes before submitting this form.

Note: Please email your relevant medical records to: pscreps@neuroci.com OR complete the NCBI's HIPPA Form on our website and we will request your records from these providers. 

Please enter your digital signature below if you are the patient or the caregiver registering for the patient consenting to your evaluation.

Submit this form by clicking the button below and you will receive an email to schedule your diagnostic appointments.

Should you wish for our Scheduling Team to manage your appointments, please contact them via email at pscreps@neuroci.com or call 973-601-0100. They will be happy to assist you.