MJIA MedPro Telemedicine RRG Form

MedPro Telemedicine RRG Form

Physician Online Communication with Patients Underwriting Questionnaire

RRG Telemedicine Form

Email address(Required)
MM slash DD slash YYYY
1. Does your practice engage in electronic communications with patients
A. If Yes is it only through a secure Internet based communication system (ie. Patient Portal)
2. Is your electronic communication with: (select all that apply)
3. Is electronic communication with patients limited to patients 18 or older
4. Which of the following transactions do you/the group conduct electronically with patients (please check all that apply)
A. Administrative uses
B. Education and health promotion
C. Patient Care
5. Do you have a written email policy?
A. If “Yes”, does your email policy include provisions to address at least the following issues: (please check all that apply)
6. Does your system meet HIPAA privacy and security rules
7. Will you be referring patients to other web sites
8. Are you/will you engage in any medically- related commercial activity on the internet?
9. Are you/will you be posting all email correspondence (sent and received) to the patient record?