Telehealth Clinical Privileges Form
Request telehealth clinical privileges by providing your professional details, requested privilege area, credentials status, and availability for review.
Applicant Information
Applicant Full Name
*
First Name
Last Name
Professional Title / Role
*
Organization or Practice Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Telehealth Privilege Request
Requested Privilege Type / Specialty Area
*
Please Select
Primary Care
Behavioral Health
Dermatology
Endocrinology
Cardiology
Neurology
Pediatrics
Psychiatry
Urgent Care
Other
States or Regions Requested
*
Northeast
Southeast
Midwest
Southwest
West
All Licensed Jurisdictions
Specific State(s)/Region(s)
Other
Primary Telehealth Services to be Provided
*
Initial Evaluations
Follow-Up Visits
Care Coordination
Patient Education
Remote Monitoring Review
Medication Management
Triage and Symptom Assessment
Chronic Disease Management
Behavioral Health Counseling
Other
Credentials and Availability
Current license or credential status
*
Please Select
Active
Pending renewal
Not yet obtained
Inactive
Other
Years of clinical experience
*
Preferred start date for telehealth privileges
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: