Telehealth Information

Telehealth Provider Verification Portal

Click here to access the UMMC Telehealth Provider Verification Portal. Registration is required and is limited to entities who have a delegated credentialing agreement on file with the UMMC Office of Telehealth.

Telehealth Professional Practice Evaluation

The form below complies with Centers for Medicare and Medicaid Services Conditions of Participation that require the distant site to collect information from the originating site that includes at least complaints and/or adverse events regarding practitioners who are providing telehealth services. The information submitted will be forwarded to the Office of Telehealth at University of Mississippi Medical Center for use in performance improvement activities.

Form

* = Required Fields

Provider Reviewed*	*
Date of Review:*	*Invalid Date
Name of Hospital or Care Setting:*	*
Date of complaint or adverse event:	Invalid Date
Details of complaint or adverse event*	*
Overall Impression* Acceptable Marginal Unacceptable *
Submitted by:*	*
Email Address:*	*Invalid Email