Telemedicine sessions are similar to routine outpatient office visits, except interactive video technology is used to communicate with your provider at a distance. 

• BENEFITS: Telemedicine visits are provided as a convenience to make it easier for you to access care at a location of your choosing without the need for travel time and costs. 

• LOCATION: You agree that your provider at R & R Psychiatric Care cannot provide telemedicine services to you if you are outside of the state of Arizona.

• POSSIBILITY FOR IN-PERSON CARE: You agree that at any time, your provider at R &R Psychiatric Care may determine that in-person care is required for clinical reasons. You also have the right to decide withdraw consent for telemedicine and receive in-person care at any time. 

• TECHNOLOGY: You understand how to operate the electronic device you’ll be using to access your telemedicine appointment. In the case that the technology and/or equipment does not work during the session, then the session will be cancelled and rescheduled. However, some technology interruption is expected, and you understand it does not discount the fees of the session unless the session is terminated. 

• RISKS: You understand that there are possible risks including technical failures, poor video or audio resolution, potential breach of confidentiality, potential for security compromise with telemedicine company, lack of access to all information available in a face-to-face visit which may result in possible errors in medical judgment, and that services may not be as complete as face-to-face services. 

• PRIVACY & SECURITY: We strongly encourage you to access telemedicine in a private location. We manage the risk of privacy and security on our end by using this technology in a private & secure manner including encrypted teleconferencing software, password protection on computers, and never leaving them unattended. We have selected Doxy.me for their quality reviews and track record but may change this provider in the future.

• LEGAL: The laws that protect privacy and the confidentiality of medical information apply to telemedicine. Your provider at R & R Psychiatric Care will complete documentation of your telemedicine visit in the same way that documentation is made for in-person care. As a general practice, R & R Psychiatric Care DOES NOT record Telemedicine sessions without prior permission.

• COST: You are responsible for fees associated with telemedicine services, which are the same as fees for face-to-face services. These fees are payable by your credit or debit card on file, which will be billed the same day as your scheduled appointment. If your card is declined, you agree to provide alternative card information to your provider during your session.

• PRESCRIBING: You may be prescribed medicine as a part of your telemedicine treatment. In accordance with State and Federal regulations, some medications may not be prescribed without an in-person physical examination or in-person care as determined by your provider at R & R Psychiatric Care.

• EMERGENCY: Specifically for telemedicine, for your safety in case of an emergency, your provider requires an Emergency Contact Person. If you are having suicidal or homicidal thoughts, experiencing symptoms of psychosis, having a medical emergency, or otherwise in a crisis that we cannot solve remotely, your provider may determine that you need a higher level of care and will contact your Emergency Contact Person to go to your location or to agree to take you to a hospital. 

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ACKNOWLEDGEMENTS

1. By continuing into my telemedicine session, I agree that I have received a copy of this Telemedicine Consent, have read and understand the information, have had an opportunity to ask questions about this information, and agree to abide by these policies and hereby give consent for telemedicine service.

2. I agree that a photocopy or electronic copy of this consent OR a file on record showing I agreed to this consent shall be considered as valid as the original. 

3. Expiration of Consent: This consent regarding telemedicine policy will expire if/when the client has closure of care with R & R Psychiatric Care.

4. If applicable, I attest that I am the legal guardian and have the right to consent on behalf of the minor client engaging in telemedicine services. ​

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