C4UH Telehealth Request
Please complete this form to request affordable telehealth for providers serving underserved patients
Email *
Send me email updates *
Legal name of your practice *
Subscriber's first name *
Subscriber's middle name/initial
Subscriber's last name *
Subscriber's license (MD, DO, PA, PA-C, NP, PhD, MFCC, MFT, LCSW, etc) *
What is your NPI (National Provider Identifier)? *
Business Address: Street *
City *
State (2 letter abbr.) *
ZIP Code *
Mobile phone *
Send me text message updates *
Business phone (for order processing questions)
Please confirm that you accept Medicare, Medicaid or underserved patients in your practice? *
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