I understand that SCPC is performing a courtesy for me by billing my insurance company and it is ultimately my responsibility to know my insurance benefits and coverage. Upon verification of health plan/insurance coverage and policy limits, my insurance carrier will be billed for me and my provider will be paid directly by the carrier. SCPC will make every effort to assist me in getting my claims correctly, however, SCPC may need to contact me to have me help resolve claim issues with my insurance company. I will be responsible for any applicable deductibles and co-payments at the time of service. I agree to make these payments at each appointment. I do have the option of paying cash, due at time of service, and then billing my insurance company directly for reimbursement. I understand that if I am not eligible at the time services are rendered, I am responsible for payment, even if the determination is made after services are rendered. I also understand that I will be responsible for a charge of $150 for any missed appointment if not cancelled prior to 48 business hours of appointment time. SCPC will have access to my payment information so as to deduct the amount upon missed appointment. By signing this agreement, I give permission to SCPC to store my credit card information for copay and missed appointment remittance.

1. I am physically located in California. At the beginning of each telemedicine session, I will help my provider complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication.

2. My provider is located in and licensed by the State of California. My provider may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. If I require medication, I may contact my provider. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help.

3. I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my provider and my provider's staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.

4. My provider believes that telemedicine services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.

5. If my provider believes at any time that another form of services (for example, a traditional in-person consultation) would be appropriate, my provider may discontinue telemedicine services and schedule an in-person consultation with my provider or refer me to a healthcare provider in my area who can provide such services.

6. I have the right to withdraw consent to the use of telemedicine services at any time and receive in-person healthcare services with my provider.

7. I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my provider and understand there are limitations to the technology which may require an in-person consultation.

8. I agree to have the necessary computer, equipment, and internet access necessary for telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine communications.

9. The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my provider to me will be encrypted during transmission and will be stored only by my provider or a service provider selected by my provider. I understand the dissemination of any personally identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or California state law.

10. I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to auto remember usernames and passwords, or use my work computer for personal communications.

11. I also understand it is my responsibility to encrypt medical information I transmit electronically to my provider and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.

12. I understand that no part of the encounter will be recorded without my written consent.

13. I have the right to access my medical information and obtain copies of my medical records in accordance with California law.

14. I understand that the telemedicine services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance.

I read and understand the information provided in this Consent to Use Telemedicine. I discussed any questions I had with my provider and all of my questions were answered to my satisfaction.

Telemedicine (also sometimes called telehealth) services are a way to deliver healthcare services locally to a patient when the healthcare provider is located at a distant site. Telemedicine is generally defined as the use of electronic information and communications technology to exchange medical information from one site to another site to provide medical or surgical treatment to a patient and/or to participate in the medical diagnosis of, or medical opinion to, a patient.

When a healthcare provider believes a patient may benefit from the use of telemedicine services, telemedicine can maintain a continuity of care with the provider and facilitate patient self- management and caregiver support of the patient. Telemedicine services often provides a broader access to medical care, eliminates transportation concerns, and increases comfort and familiarity for patients and their families when located in their own homes or other local environments.

However, telemedicine uses new communications technology for which there is little research supporting its effectiveness. For example, telemedicine services may not be as complete as in- person healthcare services because the healthcare provider will not always be able to observe subtle non-verbal communications such as a patient's posture, facial expression, gestures, and tone of voice.

Telemedicine may transfer medical information through the use of interactive, real-time audio/visual technology (for example, video conferencing) or electronic data interchange (for example, computer-to-computer exchanges), or it may transfer medical information through the use of store-and-forward technology (for example, emails). While precautions are taken to secure the confidentiality of telemedicine services, the electronic transmission of medical information can be incomplete, lost, or otherwise disrupted by technical failures. Additionally, despite such measures, the transmission and storage of medical information can be accessed by unauthorized persons, causing a breach of the patient's privacy.

I read and understand the information provided in this document. I discussed any questions I had with my provider and all of my questions were answered to my satisfaction.

We welcome you and your family members to our practice. We will do everything in our professional capacity to make the treatment as productive as possible. Please find displayed patients' rights and responsibilities in our office. It is understood that all information between patient and Psychiatrist/NP is held in strict confidentiality and will not be released unless permitted by law, including but not limited to situations involving imminent danger, suspected abuse or neglect, continuity of care, court order, or other legal requirements.

I consent to the release of information regarding my (or my child’s) care with referral sources and co-treating providers for treatment, payment, and health care operations, including claims, utilization review, quality improvement, and care coordination.

I authorize my psychiatrist/NP to perform evaluations, examinations, and treatment deemed clinically appropriate. The purpose, risks, and alternatives of treatment may be discussed upon my request. A legal guardian or authorized representative may consent on behalf of a minor or dependent patient.

I understand that So Cal Psychiatric Care may use Ambient Artificial Intelligence (AI) or digital scribe technology during in-person or telemedicine visits to assist with clinical documentation. This technology may capture audio and/or contextual information from the encounter and generate draft clinical notes for provider review. I understand that:

• The AI system does NOT make clinical decisions and is used solely as a documentation aid.
• All generated content is reviewed, edited, and finalized by my treating clinician.
• Information captured is handled in accordance with HIPAA, California privacy laws, and applicable security safeguards.
• Audio recordings, if created, are not retained beyond what is necessary to generate documentation unless otherwise required by law.
• I may request that Ambient AI technology not be used during my visit without affecting my access to care.

By signing below, I give informed consent to the use of Ambient AI / digital scribe technology for documentation of my care.

I consent to receive appointment-related SMS/text messages and understand that I may opt out at any time.

I understand that the Open Payments Database is a federal program that reports payments made by drug and device manufacturers to physicians and NPs and is available at https://openpaymentsdata.cms.gov.

Please note, SCPC holds the right to cancel your scheduled appointment if we do not receive confirmation for your appointment by 5 pm, the prior business day of your scheduled appointment.