Sample Forms & Templates
This page is intended to provide a number of sample forms and templates related to telehealth practice. It should be noted that these forms and templates are intended to be used as educational material not as strict guidance or templates to follow – rules and restrictions will vary depending on location and practice type. Any questions about specifics related to these templates and samples can be asked to the UMTRC at [email protected].
Telehealth Job Duties Descriptions and Guidance
- SAMPLE CLINICAL TELEHEALTH COORDINATOR JOB DESCRIPTION PERFORMANCE APPRAISAL
- SAMPLE CLINICAL TELEHEALTH DIRECTOR JOB DESCRIPTION
- SAMPLE SENIOR TELEHEALTH ANALYST JOB DESCRIPTION
- SAMPLE SITE TELEHEALTH COORDINATOR RESPONSIBILITES GUIDELINES
- SAMPLE TELEHEALTH ANALYST NON-MANAGEMENT JOB DESCRIPTION
- SAMPLE TELEHEALTH DIRECTOR JOB DESCRIPTION
- SAMPLE TELEHEALTH SERVICES COORDINATOR JOB DESCRIPTION
- SAMPLE TELEMEDICINE SPECIALIST JOB DESCRIPTION
Telehealth Consent Forms and Guidance
- SAMPLE CONSENT TO PARTICIPATE IN A TELEMEDICINE CONSULTATION
- SAMPLE CONSENT TO TREATMENT AND RELEASE OF INFORMATION
- SAMPLE INFORMATION NEEDS AND USE SURVEY FORM
- SAMPLE INFORMED CONSENT FOR TELEHEALTH CONSULTATIONS
- SAMPLE TELEHEALTH CONSENT FORM
- SAMPLE INFORMED CONSENT FOR TELEMEDICINE SERVICES
- SAMPLE OUTPATIENT DIABETES EDUCATION CONSENT FORM
- SAMPLE PROTOCOL FOR TELEHEALTH SCHEDULING OF ORTHO TRAUMA PATIENTS AT REHAB FORM
- SAMPLE TELEHEALTH VIDEO CONFERENCING AGREEMENT FORM
- SAMPLE TELEMEDICINE CONSENT FORM
Telehealth Consultation Forms and Guidance
- SAMPLE PRECONSULT ASTHMA HISTORY FORM FOR TELEHEALTH SERVICES
- SAMPLE PSYCHIATRIC MENTAL HEALTH CONSULTATION BY TELEMEDICINE FORM
- SAMPLE PULMONLOGY TELEHEALTH CONSULTATION FORM
- SAMPLE STORE AND FORWARD TELEDERMATOLOGY TEMPLATE GUIDELINES FOR REFERRING PHYSICIANS
- SAMPLE TELEDERMATOLOGY CONSULTATION FORM
- SAMPLE STROKE ORDER GUIDELINE FORM
- SAMPLE TELEHEALTH APPOINTMENT LOG TEMPLATE
- SAMPLE TELEHEALTH AUTISM ENCOUNTER FORM
- SAMPLE TELEHEALTH DERMATOLOGY ENCOUNTER FORM
- SAMPLE TELEHEALTH GENETICS OUTREACH ENCOUNTER FORM
- SAMPLE TELEHEALTH ORTHOPAEDIC PROTOCOLS
- SAMPLE TELEHEALTH PHYSICAL MEDICINE AND REHABILITATION CLINIC ENCOUNTER PROTOCOL FORM
- SAMPLE TELEHEALTH PREOPERATIVE EVALUATION FORM
- SAMPLE TELEHEALTH PSYCHIATRIC ENCOUNTER FORM
- SAMPLE TELEMEDICINE CONSULTANT EVALUATION FORM
- SAMPLE TELEMEDICINE PATIENT EVALUATION FORM
- SAMPLE TELERADIOLOGY PROCEDURES FORM SENDING INSTRUCTIONS
- SAMPLE TELESTROKE BRAIN ATTACK AMBULANCE PROTOCOL FORM
- SAMPLE TELESTROKE CLERK PROCEDURE FORM
- SAMPLE TELESTROKE MD PROCEDURE FORM
- SAMPLE TELESTROKE RN PROCEDURE FORM
Telehealth Research Forms and Guidance
Telehealth Business Forms and Guidance
- SAMPLE TELEMEDICINE CONSULTATIONS BUSINESS AGREEMENT TEMPLATE
- SAMPLE TELEMEDICINE NETWORK PROVIDER AGREEMENT
More questions? Contact the UMTRC at [email protected]!
Last updated March 24th, 2023