Telehealth Services Form – Multiple Site Submission

This form is best utilized by organizations that have multiple clinics under the same parent umbrella.

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, or (406) 640-1230

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