Background: Telehealth may redress rural healthcare shortages in the United States and improve related rural health disparities. However, following the expansion of telehealth related to the COVID-19 pandemic, telehealth utilization has been lower among rural populations compared to urban populations. Certain populations are also more likely to use audio-only telehealth, with implications for care quality. Objective: To describe demographic and telehealth utilization characteristics of a population of rural-dwelling adult patients and explore relationships of these characteristics with patients’ level of rurality and with modality of patients’ most recent telehealth encounter. Methods: Retrospective medical record review of adults who lived in rural California ZIP codes and utilized telehealth at an urban medical center from December 2021 to December 2022. Rural-Urban Commuting Area Codes were used to assign rurality and to group patients by three levels of rurality. Telehealth visits were defined as video-enabled and telephone encounters with any provider type. Demographic variables included age, race or ethnicity, preferred language, payer, and online patient portal activation status, as proxy for digital health literacy. Telehealth encounter variables were video or telephone modality, visit provider, and specialty area. Chi Square and Fisher’s Exact tested associations of demographic and encounter characteristics with patient level of rurality and telehealth encounter modality. Results: A total of 9,359 patients were included. Telehealth patients living in the most rural ZIP codes were older, and a higher proportion were White, compared to those in less rural ZIP codes. Patients who were American Indian, Asian, Black, and Latino together comprised 25% of the sample, lower than their average population in rural California counties. Video visit use was significantly lower among patients who were older than 65 years (91.3% versus 93.8% under 65 years; 2(1) = 19.3, P<.001 latino race or ethnicity versus among white patients p=".008)," primary spanish speakers english fisher exact and publicly insured medicare medicaid privately patient portal activation was lower latinx spanish-speakers english-speakers conclusions: findings substantiate concerns of rural telehealth access disparities particularly who are older minoritized spanish-speaking. ongoing research is needed to understand how underserved populations utilizing telehealth. address utilization policy should patient-level barriers by supporting measures such as healthcare navigation resources culturally tailored outreach digital assessment education. evidence-based reimbursement essential support provider-side barriers.>