Collaboration Compliance Review

Please complete this quick monthly compliance review designed to ensure compliance and review collaboration requirements.

Physician Information
1 What state(s) do you collaborate with this provider?
2 Have patients been seen this month?
Why not?
3 Have you had a check-in with your collaborator this month?
Date of meeting:
Why not?
4 Has quality assurance occurred this month?
Choose only which ones apply this month:
Why not?
5 Have you reviewed patient charts this month?
How many charts have you reviewed?
Why not?

By submitting this form, I attest that the information provided above is accurate and complete to the best of my knowledge, and that I have fulfilled my collaboration obligations in accordance with applicable state regulations and the terms of my collaboration agreement.

I attest that the above information is accurate and complete.

Your response will be sent securely upon submission.

Please remember our three compliance commitments

To ensure a successful, compliant collaboration, we ask all of our physicians to uphold the following:

  1. Monthly Check-In — Connect with your provider at least once per month via your preferred method to offer guidance and maintain availability.
  2. Urgent Consultation — Be available for urgent consultation within 2 hours of a request (this is rare, but important).
  3. Routine Communication — Respond to non-urgent questions and requests within 24 hours.