Telehealth Services Form – Multiple Site Submission

Form Instructions (Designed for a web browser, not mobile devices)

This form is best utilized by organizations that have multiple clinics under the same parent umbrella.
  • Begin typing the name of the health system, select the name and push “search”
  • A list of locations that will be included in the telehealth platform are listed in the resulting grid
  • Use the “edit” button on the far-right column next to each site to update the following six fields:
    1. In-Person Services: What medical services does your facility provide in-person?
    2. Telehealth Offered: Is this facility a point of access for patients to access telehealth services?
    3. Telehealth Only: If you only provide services via telehealth, select yes.
    4. Telehealth Services: What telehealth services can patients access through telehealth programs affiliated to this practice?
    5. Translation Services: If you provide telehealth services, do you offer translation services for the telehealth visit?
    6. States Served: In what states do patients need to be located to access these telehealth services?
    7. New Patients: Are outpatient telehealth services available to new patients?
    8. Telehealth Contact: Who should we send this form to next year?
    9. Email: What is the email for the person we should send this form to next year?
  • Push update and “edit” the next location
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If you have questions, comments, or would like to review the form with someone please contact Jena Smith:
Jena Smith, [email protected] or (406) 640-1230