Telehealth Sample Forms and Guidelines

The California Telehealth Resource Center (CTRC) curated or developed sample forms, which are available for use when implementing a telehealth program.

• Consent #1 (English) and  Consent #1(Spanish)

• Consent #2 (English) (obtained from the Cooperative of American Physicians)

  • COVID-19 Consent for Telehealth Consultation (obtained from TRMS)

  • COVID-19 Informed Consent for Telehealth  (obtained from TRMS)

• Common Integration Barriers

• Credentialing by proxy – OVERVIEW

• CTeL Credentialing and Privileging Checklist

• Job Descriptions

• Clinic Telehealth Policy (Shared by the North Country Telemedicine Pilot Program)

• Policy and Procedure Template (obtained from AHIMA)

• Policy and Procedure Guidelines

• Questions to ask a Specialty Service Provider

• Referral Guideline Neurology Pediatric

• Referral Request Form

• Sustainability Worksheet IHC FQHC RHC

• General Telehealth Workflow Example

• Clinic to Patient Workflow Example

• Clinic to Clinic Workflow Example

• UMTRC Patient to Provider Workflow Example
  

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