Create Telemedicine Service Agreements Easily

Step 1: Healthcare Provider & Patient Information

Healthcare Provider Information

Healthcare Provider Name *

Provider Type *

Business Address *

Phone Number *

Email Address *

Primary Physician Name

Medical License Number

DEA Number

NPI Number

Medical Specialties

Board Certifications

Patient/Client Information

Patient Name *

Date of Birth

Patient Address *

Phone Number *

Email Address *

Emergency Contact Name

Emergency Contact Phone

Insurance Provider

Policy Number

Group Number

Patient Consent Authorization

Consent to Telemedicine Services

Consent to Session Recording (if applicable)

Consent to Medical Data Sharing

Step 2: Telemedicine Services & Technology Platform

Telemedicine Services Offered

Types of Services Provided

Medical Consultations

Diagnosis & Assessment

Prescription Services

Follow-up Care

Mental Health Services

Chronic Disease Management

Preventive Care

Detailed Service Description

Typical Session Duration

Service Availability

Treatment Limitations & Exclusions

Technology Platform & Requirements

Telemedicine Platform

Platform Type

Patient Technical Requirements

Data Security & Encryption

End-to-End Encryption

HIPAA Compliance

Automated Data Backup

Access Controls & Authentication

Medical Record Management

Technical Support Availability

Scheduling & Appointment Management

Appointment Scheduling

Cancellation Policy

Rescheduling & No-Show Policy

Emergency Procedures

Step 3: Financial Terms & Insurance

Service Fees & Payment Structure

Consultation Fee ($) *

Fee Structure *

Follow-up Session Fee ($)

Urgent Care Fee ($)

Prescription Service Fee ($)

Technical Support Fee ($)

Accepted Payment Methods

Credit/Debit Cards

Direct Insurance Billing

HSA/FSA Cards

Cash/Check

Payment Plans

Payment Terms

Refund & Cancellation Policy

Insurance & Coverage

Insurance Plans Accepted

Medicare

Medicaid

Private Insurance

Employer Health Plans

No Insurance Accepted (Self-Pay Only)

Patient Copay ($)

Deductible Applies

Insurance Billing Process

Coverage Limitations

Financial Assistance & Programs

Financial Assistance Available

Sliding Fee Scale

Payment Plans

Charity Care Program

Hardship Discounts

Financial Assistance Eligibility

Step 4: Legal Terms & Compliance

HIPAA Compliance & Privacy

HIPAA Compliance Measures

Business Associate Agreement

Encrypted Data Transmission

Secure Data Storage

Access Audit Logs

Staff HIPAA Training

Medical Data Retention Policy

Data Sharing & Third Parties

Patient Rights & Access

Malpractice & Liability

Malpractice Insurance

Coverage Amount ($)

Liability Limitations

Informed Consent Requirements

Standard of Care

Legal Terms & Dispute Resolution

Service Termination

Dispute Resolution

Governing Law (State) *

State Licensure Compliance

Regulatory Compliance

Emergency Services Disclaimer

Additional Terms & Conditions

Telemedicine Service Agreement Generator

Step 1: Healthcare Provider & Patient Information

Step 2: Telemedicine Services & Technology Platform

Step 3: Financial Terms & Insurance

Step 4: Legal Terms & Compliance

Frequently Asked Questions

Telemedicine Service Agreement Generator

Step 1: Healthcare Provider & Patient Information

Step 2: Telemedicine Services & Technology Platform

Step 3: Financial Terms & Insurance

Step 4: Legal Terms & Compliance

Frequently Asked Questions

What is a Telemedicine Service Agreement?

Why use LeaseCraft for Telemedicine Agreements?

Are the agreements generated by LeaseCraft state-specific?