Offender Intervention Telecommunication Services Application
Date
*
-
Month
-
Day
Year
Date
Provider Name
*
First Name
Last Name
Provider License Number
*
Attach Proof of Licensure
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Organization
*
Provider Email
*
example@example.com
Provider Phone Number
*
Please enter a valid phone number.
Provider Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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, the program agrees
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:
*
Separated by commas
Attach proof of licensure
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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 (HIPPA) and state privacy, confidentiality and medical retention rules:
*
Does your insurance cover telecommunication services?
*
Yes
No
Program agrees to verify insurance coverage of telecommunication services for participants who are paying for services through insurance.
*
Yes, the program agrees
By signing below, I certify all information is true and correct to the best of my knowledge.
Signature
*
Name of person submitting form
*
First Name
Last Name
Submit
Should be Empty: