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Telemedicine Services Agreement

Start entering into telemedicine agreements with physicians using this Telemedicine Services Agreement Form Template. Copy this form template to your Jotform account for free!

Telemedicine Services Agreement

Please fill out the following information to enter into a telemedicine services agreement.

Email*

Full Name*

Organization Name*

Address*

City*

State*

Zip Code*

Phone Number*

Fax Number*

10.

Email Address*

11.

Physician's Full Name*

12.

Physician's License Number*

13.

Physician's NPI Number*

14.

Physician's DEA Number*

15.

Physician's Address*

16.

Physician's City*

17.

Physician's State*

18.

Physician's Zip Code*

19.

Physician's Phone Number*

20.

Physician's Fax Number*

21.

Physician's Email Address*

22.

Effective Date*

Select date

23.

Agreement*

I agree to the terms and conditions of this Telemedicine Services Agreement.

Description:Enter into telemedicine agreements with physicians using this free Telemedicine Services Agreement Form Template. Copy this form to your Jotform account and start providing remote healthcare services.

Telemedicine has revolutionized the healthcare industry by providing remote healthcare services to patients. With the increasing demand for telemedicine services, it's important to have a Telemedicine Services Agreement in place to ensure that both parties are aware of their rights and responsibilities. This Telemedicine Services Agreement Form Template is designed to help healthcare providers enter into telemedicine agreements with physicians. By using this form template, you can easily outline the terms and conditions of the agreement, including the scope of services, payment terms, confidentiality, and liability. This form template is fully customizable, allowing you to add or remove fields as needed. With Jotform, you can easily share this form with physicians and patients, collect electronic signatures, and store all agreements securely in the cloud. Start providing remote healthcare services today with this Telemedicine Services Agreement Form Template.

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