Credentialing by Proxy Request Form

Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Telemedicine is not a separate medical specialty. Telehealth is an expansion of telemedicine, and unlike telemedicine (which more narrowly focuses on the curative aspect) it encompasses preventative, promotive and curative aspects.

What is Credentialing by Proxy?

The Originating Site is allowed to accept the privileges decisions of the Distant Site.

• Originating Site: The site where the patient is located at the time the service is provided.
• Distant Site*: The site where the practitioner is located while providing the professional service.

*Distant Site must be a Joint Commission accredited organization with deemed status by CMS.

The Originating Site, through a written contract with the Distant Site, accepts the credentialing and privileging decisions of the Distant Site.

The Distant Site must comply with all applicable Medicare regulations and accreditation standards.

Both organizations are to follow applicable laws/regulations to practice medicine or telemedicine in the states where the Originating Sites and Distant Sites are located.

Please complete the eform below in order to start the Credentialing by Proxy request.

If you have any questions about this process please email Staci Hightower.