General
I consent to engage in telemedicine with my CCBH provider. I understand that telemedicine is the delivery of healthcare services using interactive audio and videoconferencing equipment where the provider and patient are in different locations.
Confidentiality and Rights
I understand that all existing laws, rules and regulations associated with the practice of medicine in the State of California continue to apply to telemedicine.
I understand that both the patient and the provider may withhold/withdraw their consent for the use of telemedicine at any time. This will not affect my other care or treatment.
I agree not to record the telemedicine sessions without prior written consent from the provider and CCBH. I understand that my CCBH provider will not record the telemedicine sessions without my prior written consent.
The CCBH provider will conduct the sessions in a private area and will notify the patient if anyone else is present. I agree to inform the provider if any other person is in the room or can hear or see any aspect of the session at any time.
I understand that I must be residing in California and be physically present in California during the appointment to receive telemedicine services from CCBH.
Limitations / Risks
I understand that there are potential risks to this technology and that telemedicine is an alternative to face-to-face treatment but may not be as complete as in person treatment.
Reasonable efforts have been made to eliminate risks but unauthorized access of the transmission and/or electronic storage of healthcare information is possible where the information could be accessed by unauthorized individuals. Other risks include but are not limited to technical difficulties, interruptions and distortions in the transmission of the audio or visual information.
If you have Medi-Cal
If you have Medi-Cal, including through Contra Costa Health Plan: you have the right to receive covered services in person instead of by telehealth; using telehealth is voluntary, and you may withdraw your consent at any time without affecting your ability to get Medi-Cal covered services in the future; Medi-Cal covers non-medical transportation to in-person visits; and telehealth has the limitations and risks described above. If you would rather be seen in person, tell us and we will offer an in-person visit or a referral.