Self Pay Consent

Thank you for choosing CS Connect for your visit today.
Our cash rates for telehealth visits are:

• New Patient Visit: $250
• Established Patient Visit: $200

Please note, these charges will be applied after services are rendered. By receiving services, you acknowledge and agree to the following:

• Billing Process: You will be balance billed after your visit. A statement of services provided and amount due will be sent to you.
• Payment: We kindly ask you pay your bill upon receipt.
• You are not receiving or eligible for Medi-Cal Coverage.

If you have any questions or need to explore financial assistance options (including options for Medi-Cal patients), please contact our office at 866-803-1777 or via email at patient.billing@cshs.org.