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.