TeleHealth Solution Intake Form

Filling out this form represents an application that has to be validated by our internal Quality Assurance team. Once successfully vetted, your information will be visible on the website.

Basic Information

What platforms does your solution support?

Description

Solution Image

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Max File Size 15MB

Does your solution require client software to be downloaded?

Which mobile platforms does your solution support?

Financial Commitment

Is a free trial available?

Initial Setup Cost

Free Trial Period

Cost Per Patient

Price

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Solution Uptake

Installed User Base

Active User Base

Annual Retention Percentage

Platform Integrations

Practice Management Tools

Support for Patient Scheduling 

Support for Healthcare Waiting Room

Support for Enterprise Analytics and Reporting

Support for Payment Management

Lab Tests

Level of Support

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Electronic Medical Records

Level of Support

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Prescriptions

Level of Support

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Remote Patient Management

Level of Support

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Clinical Workflow

Is your solution customizable to a new clinical workflow?

Does your solution add an additional item or step in the clinical workflow of a doctor or practice?

Care Support

Does your solution allow patients to add family members and caregivers to their care team?

Does your solution support group therapy?

Does your solution support population health, i.e. segmentation of patient populations, predictive analytics, etc. ?

Does your solution support chronic disease management?

Does your solution support auto-scheduling for chronic disease management?

Technology Constraints

Maximum Number of Suggested Videoconference Attendees

Does your solution have low bandwidth support?

What is your evaluation of your solution's audio quality?

What is your evaluation of your solution's video quality?

What is your evaluation of the quality of your solution's audio-video synchronization?

Does your solution have accessibility controls?

Date of Last Security Audit

Encryption Algorithm Used

Encryption Key length (in bits)

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HIPAA Compliance

Do you have HIPAA administrative safeguards in place?

By clicking YES, you are confirming that you have documentation and controls in place to address risk analysis, risk management, sanction policy, information system activity review, assigned security responsibility, authorization and supervision, workforce clearance procedures, termination procedures, access authorization, access establishment and modification, unauthorized access, security reminders, protection from malicious software, log-in monitoring, password management, incident response and reporting, data backup, disaster recovery, emergency mode operation, testing and revision procedures, applications and data criticality analysis, contingency plan evaluation, and business associate arrangements.

Do you have HIPAA physical safeguards in place?

By clicking YES, you are confirming that you have documentation and controls in place for facility contingency operations, facility security plan, facility access control and validation procedures, facility maintenance records, workstation use policies and procedures, workstation security policies and procedures, device and media disposal, media re-use, device and media accountability, and data backup and storage.

Do you have HIPAA technical safeguards in place?

By clicking YES, you are confirming that you have documentation and controls in place for unique user identification, emergency access, automatic logoff, data encryption and decryption, audit controls, authentication mechanisms for electronic protected health information, person or entity authentication, transmission integrity controls, and transmission encryption.

Do you have safeguards in place to comply with HIPAA's Privacy Rule?

By clicking YES, you are confirming that you have policies and procedures in place to address elements of the Privacy Rule regarding uses and disclosures of personal health information, organization requirements,  consent requirements, authorization requirements, attempted approval requirements, approval requirements, disclosure requirements, notice of privacy practices, request of privacy protection, access of individuals to protected health information, amendment to personal health information, accounting for personal health information, and administrative requirements.

Do you have controls in place to comply with HIPAA Breach Notification guidelines?

By clicking YES, you are confirming that you have policies and procedures in place to provide notification following a breach of unsecured protected health information.

Documents & Certifications

Please provide a copy of your HIPAA Business Assoiate Agreement

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Max File Size 15MB

Please provide a copy of your HIPAA Compliance Statement

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Max File Size 15MB

Please provide a single zip file of your certifications

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Max File Size 15MB

Point of Contact

*Please allow a few seconds after you press SUBMIT for the form to process.

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