Home       Search       Sitemap


Click to learn more about what Telehealth means for the physician.
Request for Telehealth Benefit Assessment
Facility Name

Facility Type

Patient Visits

Patient Transports

Current ISP

Your Name

ADDRESS

CITY

STATE

PHONE

EMAIL
- fields necessary to fill



















Other Notes

Information Required
Facility Type
Is your facility a Hospital, Clinic, Long-Term Care, or a Correctional Instituition (i.e. Prison)?
Patient Visits
Average number of patient visits per day?
 
Patient Transports
Average number of patients who need transportation assistance to specialists, hospitals or LTC facilities, per day?
 
Current ISP
The name of your current Internet Service Provider?
 
Other Notes
In this free-form area you can enter other information you feel may be pertinent...
 
 
ATA - American Telemedicine AssociationTIE - Telemedicine Information Exchange