Offender Intervention Telecommunication Services Application

Offender Intervention Telecommunication Services Application
Date

MonthDay Year
Date
Provider Name

First Name Last Name
Provider License Number*
From the Division of Occupational & Professional Licenses
Attach proof of licensure*

Browse Files

Cancelof
Organization*
Provider E-mail*
Provider Phone Number*

Area Code Phone Number
Provider Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Program Information
Please list the counties to be served through remote access:*
Please reference "statewide" if offering remote access in all counties.
Address of program:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Describe how your program will operate to meet the ICDVVA standards, inclusive of written policy and procedure:
Program agrees to provide telecommunication services ONLY for those clients who have been approved by the court for remote participation.*

Yes

Remote Session Location
Organization Name:*
Session Location Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
List each provider conducting telecommunication services.*
Attach proof of licensure for each provider.*

Browse Files
From the Division of Occupational & Professional Licenses. Use the Ctrl key to add multiple license files at once. Cancelof

Telecommunication Information
Name of telecommunication service:*
Zoom, Webex, etc.
Describe how the service meets or exceeds applicable federal and state legal requirements of medical.health information privacy, including compliance with the Health Insurance Portability and Accountability Act (HIPAA) and state privacy, confidentiality and medical retention rules:*
Does your insurance cover telecommunication services?*

YesNo
Program agrees to verify insurance coverage of telecommuniation services for participants who are paying for services through insurance.*

Yes
By signing below, I certify all information is true and correct to the best of my knowledge.
Signature *

Clear
Name of Person Submitting Form*

First Name Last Name
Should be Empty:

Program Information