Telehealth Services Form – Health Systems

Your response to this request will assist patients in identifying points of access to telehealth services in Wyoming, Idaho, Montana, Alaska, Washington, Oregon, and Utah. The Northwest Regional Telehealth Resource Center (NRTRC) has developed a free, public-use telehealth services locator. Ensure your health system is correctly represented by completing the form below.

Form Instructions

  • 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 locator 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 Services: What telehealth services can patients access through this facility?
      • Remember, these fields will be used to help patients identify this facility as a point of access to in-person and telehealth services.
    4. Translation Services: If you provide telehealth services, do you offer translation services for the telehealth visit?
    5. Telehealth Only: If you only provide services via telehealth, select yes.
    6. Telehealth Only Service Area: If you only provide services via telehealth, in which states are services provided?
    7. New Patients: Are telehealth services available to new patients?
    8. Telehealth Access: What options describe your telehealth services?
    9. Telehealth Coordinator: Who should we send this form to next year?
    10. Email: What is the email for the person we should send this form to next year?
  • Push update and “edit” the next location

If you have questions, comments, or would like to review the form with someone please contact Jena Smith:
Jena Smith, jena@wimtracking.com or (406) 640-1230

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