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
Click here to load this Caspio Online Database.

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