Provider Contact Form

Thank you for your interest in joining the US TeleMed Services “Network of Providers”. Upon completion of our credentialing process you will be able to provide your services, remotely from a location of your choice, to our members through the use of the latest Telemedicine equipment.


Please use the below form to contact us and our credentialing/contracting staff will reach out to you shortly to begin your application.

Fields marked (*) are required
Identifying Information
Name*:
Practice Name*:
Email*:
Telephone Number*:
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Office Information
Office Contact*:
Address*:
City*:
State*:
Zip*:
Telephone Number*:
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Fax Number:
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Practice Type*:
Professional Information
Specialty*:
State Licensed in?*:
Comments:

All information submitted via our “Provider Contact Form” is kept confidential and not shared with anyone.