Telehealth Forms & Templates
Credentialing
Resources to Assist with Implementation of CMS Rule
The Centers for Medicare and Medicaid Services’ final rule on credentialing and privileging requirements for telehealth practitioners became effective on July 5, 2011. This rule establishes a process for originating site hospitals (location of the patient) to rely on the credentialing and privileging decisions of the distant site hospital (location of the specialist) for telehealth practitioners.
Members of the Wyoming Telehealth Consortium have been keenly interested in the issue of credentialing and privileging of telehealth practitioners, and offer the following resources for hospitals and practitioners as they work to implement the CMS rule.
- Federal Register link to final CMS rule (pdf) »
- Sample Credentialing and Privileging Written Agreement–Hospital to Hospital, provided by the Center for Telehealth & eHealth Law (CTeL) (pdf) »
- Sample Credentialing and Privileging Written Agreement–Hospital to Telemedicine Entity, provided by the Center for Telehealth & eHealth Law (CTeL) (pdf) »
- CTeL’s Special Report on CMS’s final rule on Credentialing and Privileging of Telehealth Practitioners (pdf) »
- CTeL Credentialing and Privileging site »
- American Hospital Association comments on CMS final rule (pdf) »
Facility Specific
AFHCAN
NRTRC
- Patient Consent Form (NRTRC)
- Patient Encounter Form Instructions (NRTRC NEW)
- Patient Rights for Telehealth Encounters (NRTRC NEW)
- Provider Agreement Template (NRTRC)
NWTH
- Mental Health Protocol (NWTH)
- Patient Consent Form (NWTH)
- Emergency Telemedicine Consult Form (NWTH)
REACH
- Patient Consent Form (REACH)
- Patient Provider Encounter Checklist (REACH)
- Patient Provider Encounter Scheduling (REACH)
- Provider Encounter Instructions (REACH)
