Telemedicine consent

I understand that there are potential risks to using technology to conduct this medical visit, including service interruptions, interception, and technical difficulties.

If it is determined that the electronic connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

I understand that I have the right not to participate or decide to stop participating in a telemedicine visit. I also understand that my refusal will not affect my right to future care or treatment.

I understand that I may revoke my consent at any time by contacting the Austin Psychiatric Alliance at (512)637-9090.

I understand that my health care information may be shared with other individuals for scheduling and billing purposes.

I understand that my insurance carrier will have access to my medical records for quality review/audit.

I agree that I am responsible for any out-of-pocket costs, including deductibles, copayments, or coinsurances, that apply to my telemedicine visit.

I understand that health plan payment policies for telemedicine visits may be different from polices for in-person visits.

We accept the following insurance plans: Blue Cross Blue Shield, United Healthcare, and Aetna plans.

We are not currently accepting NEW Medicare patients, and we are not accepting Medicaid.

We do not accept single case agreements or other insurance plans not listed.

Private pay rates are fees for out-of-pocket expenses. This is only applicable if you do not have insurance coverage, or if we are out-of-network with your insurance plan (see above for accepted insurances).

Initial Evaluation Appointment: $500
Follow-Up Appointment: $175

Please Note: If you are insured with an Out-of-Network insurance carrier, you may opt to utilize our Private Pay Rates, and request a coding receipt to submit to your insurance plan to file a claim for reimbursement with your individual plan.

Prior to your initial appointment, our staff will confirm your insurance benefits with your individual insurance plan, and alert you to your patient responsible portion (i.e. co-pay, deductible, or coinsurance) of your visit. We provide this service as a courtesy to our patients to make your appointment as easy as possible.

If you would like to check your benefits with your insurance company, call the 800 number listed on your insurance card and ask your insurance representative to help you determine your benefits for BEHAVIORAL HEALTH and/or MENTAL HEALTH services. The representative at your insurance company will help you determine if you have a deductible, co-pay, coinsurance or any limits on coverage.