North County Neurosurgery Telehealth Patient Consent

1. I agree to receive health care services via telehealth. I understand that:

• I have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth.
• The use of telehealth is voluntary and I may withdraw my consent or stop receiving services through telehealth at any time without affecting my ability to access covered services in the future.
• Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted.
• There may be limitations or risks related to receiving services through telehealth as compared to an in-person visit. For example, we are unable to directly examine you, examine a wound, which can increase the risk of misdiagnosis or lead to a delay in diagnosis.

2. I have read this document carefully, understand the potential limitations and risks of receiving services via telehealth, and have had my questions answered to my satisfaction.

Knowing all of this, do you want to have the option of receiving services from us now or in the future via telehealth?