Teledermatologist Application
Please complete
and submit the information below. Your information will be kept
confidential and will not be sold or shared with parties not directly
involved with Teledermatology consultations. Your submission of this
information does not obligate you to TeleDerm Solutions. After you
submit your application you will be contacted to discuss a potential
formal agreement with TeleDerm Solutions, Inc.
Personal
Information
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First
Name:
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Middle
Name:
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Last
Name:
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Title:
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Address
1:
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Address
2:
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City:
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State/Province: |
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Zip/Postal: |
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Country:
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Phone:
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Fax:
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Cell:
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Email:
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URL:
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Licensure
and Certification
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State(s)
in which you are licensed (i.e. TX, LA, etc.):
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Location
of dermatology residency program:
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Are
you board certified in dermatology?
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If
so, what year?
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Other
Areas of Specialization
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Medical
school and year graduated:
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In
which type of setting(s) do you practice?
(Can select multiple, Ctrl+Click)
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If
other, please specify:
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In
which areas have you completed a fellowship?
(Can select multiple, Ctrl+Click)
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If
other, please specify:
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Insurance
Information
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Malpractice/Insurance
carrier:
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Contact
name:
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Phone:
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Have
you been part of any malpractice suits?
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If
Yes, provide details:
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Does
your insurance carrier cover you for the practice of telemedicine in
the
state in which you are licensed?
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If
Yes, which states? (i.e. TX, LA, etc.)
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Does
your insurance carrier cover you for the practice of telemedicine in
other states?
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Yes, which states? (i.e. TX, LA, etc.) |
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Teledermatology
Experience
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In
which areas do you have teledermatology experience?
(Can select multiple, Ctrl+Click)
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If
other, please specify: |
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General
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How
did you hear about TeleDerm Solutions?
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