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    Main Information
  1. Do you have Telemedicine Experience?
  2. How would you rate your Telemedicine expertise?
  3. What is your interest?
  4. What would be your ideal work schedule?
  5. What month would you be available to start?
  6. Choose the primary telemedicine Specialty that you’re interested in providing.*
  7. Choose the secondary telemedicine Specialty that you’re interested in providing.
  8. Choose the tertiary telemedicine Specialty that you’re interested in providing.
  9. Choose the specialty(s) in which you are board certified to provide Telemedicine.*
    hold ctrl+click (PC) or cmnd+click (Mac) to select more than one option
  10. Choose the State that you currently hold an active license.*
    hold ctrl+click (PC) or cmnd+click (Mac) to select more than one option
  11. Has the applicant ever been convicted of a crime in connection with controlled substance(s) under state or federal law, or been excluded or directed to be excluded from participation in a medicare or state health care program, or any such action pending?*
  12. Has the applicant ever surrendered (for cause) or had a federal controlled substance registration revoked, suspended, restricted or denied, or is any such action pending?*
  13. Has the applicant ever surrendered (for cause) or had a state professional license or controlled substance registration or medical facility or hospital privileges revoked, suspended, denied, restricted, or placed on probation, or is any such action pending?*
  14. If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association, partnership, or pharmacy, has any officer, partner, stockholder or proprietor been convicted of a crime in connection with controlled substance(s) under state or federal law, or ever surrendered or had a federal controlled substance registration revoked, suspended, restricted or denied, or ever had a state professional license or controlled substance registration revoked, suspended, denied, restricted, or placed on probation, or is any such action pending?*