Mapping Telehealth Programs in the Northeast

Many thanks for your interest in listing your telehealth program in "Find Telehealth Providers" for the northeast region!
If your organization or practice is located within CT, MA, ME, NH, NJ, NY, RI, or VT and you'd like us to add you to the "Find Telehealth Providers" database and map, please provide the information requested below. Please note that some fields are required, so that we can accurately map your location.
 
If you have questions regarding the "Find Telehealth Providers" tool or NETRC, please don't hesitate to contact us at: 
netrc@mcdph.org  or  1-800-379-2021.

Site Demographics:
Organization or Practice Name

Question Title

* Organization or Practice Name

Primary Contact Information (will be used to request annual updates, but will not be publicly available)

Question Title

* Primary Contact Information (will be used to request annual updates, but will not be publicly available)

Provider/Organization Website:

Question Title

* Provider/Organization Website:

Physical address of site(s) providing telehealth services

Site 1 (a pin will be placed on the map at this location):

Question Title

* Physical address of site(s) providing telehealth services

Site 1 (a pin will be placed on the map at this location):

Site 2 (a pin will be placed on the map at this location)

Question Title

* Site 2 (a pin will be placed on the map at this location)

Site 3 (a pin will be placed on the map at this location)

Question Title

* Site 3 (a pin will be placed on the map at this location)

Site 4 (a pin will be placed on the map at this location) 

Question Title

* Site 4 (a pin will be placed on the map at this location) 

Please email netrc@mcdph.org if you would like to map more than 4 sites
Site Type (if applicable)

Question Title

* Site Type (if applicable)

If you are a spoke site, please list all hub sites that you currently work with:

Question Title

* If you are a spoke site, please list all hub sites that you currently work with:

Provider Setting Type (choose all that apply):

Question Title

* Provider Setting Type (choose all that apply):

Types of Telehealth you Currently Provide (select all that apply):
General Telehealth Utilizations:

Question Title

* General Telehealth Utilizations:

Telehealth Specialty Areas/Programs you Provide (select all that apply):
Telemedicine

Question Title

* Telemedicine

Population Based Screening

Question Title

* Population Based Screening

Telerehabilitation

Question Title

* Telerehabilitation

Women's Health

Question Title

* Women's Health

Other Telehealth Services (please list any not available above, separated by a comma)

Question Title

* Other Telehealth Services (please list any not available above, separated by a comma)

Do you have any plans to expand your telehealth services?

Question Title

* Do you have any plans to expand your telehealth services?

If yes, please elaborate on your plans for expansion:

Question Title

* If yes, please elaborate on your plans for expansion:

Many thanks for your time and assistance in advancing telehealth in the northeast!
Please visit our website to view the "Find Telehealth Providers" map, or to learn more about NETRC.

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