Telehealth Practitioner Application

Telehealth Practitioner Application

Nurse Practitioners in All 50 States: Please allow 5 business days for a response.
PERSONAL INFO
Full Name & Designation*

First NameMiddle NameLast NameDesignation
Preferred Name

First NameLast Name
Date of Birth*
Certifications*
State(s) Licensed to Practice
Do you have the authority to write scripts?*

YesNo
Is your malpractice insurance policy current?*

YesNo
Do you have a current sponsoring or supervising MD?*

YesNo
Your Email*
example@example.com
Mobile Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Verify Number*
EXPERIENCE
Number of years and months as a licensed practicing NP*
Estimate number of career video telehealth appointments*
Briefly describe your experience with telehealth*
What technologies below are you comfortable managing without training or support? (select all that apply)*

Home ComputerSmartphone or TabletInternet Connection / WifiBrowserEmailTextingPersonal SchedulingOnline Calendar & TasksEHR/EMR TasksSelf-directed TrainingZoom VideoOnline Banking
For which technologies below would you need training? (select all that apply)*

Home ComputerSmartphone or TabletInternet Connection / WifiBrowserEmailTextingPersonal SchedulingOnline Calendar & TasksEHR/EMR TasksSelf-directed TrainingZoom VideoOnline Banking
INTERESTS
What is your interest in telehealth? (select all that apply)*

Work from homeWork flexibilityBetter hoursHigher incomeNo mandatesBetter outcomesBe your own boss
Are any of the following unattractive to you? (select all that apply)

Predefined protocolsSelling specific productsWriting for independent pharmaciesReferring-out your patientsCollecting paymentTrouble-shooting Zoom videoPerfomance measurementTaking online job training
AVAILABILITY
How many hours per week could you dedicate to telehealth?*
What is your monthly income goal?*
(example: $20,000/month)
If our company is a fit for you, what date are you available to start?*

MonthDayYear
Date
How did you hear about us?*
If referred by one of our Providers, please enter their name

First NameLast Name
Anything you would like to share
Upload your Resume

File types: *.pdf or *.docx
Cancelof
Please allow 5 business days for a response. All applicants will receive an email response.

All contracted telehealth professionals are required to complete 10 hours of video-based training before their first appointment, and another 10 hours of training within the first 60 days.
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Telehealth Practitioner Application

PERSONAL INFO

EXPERIENCE

INTERESTS

AVAILABILITY