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