Collaboration Compliance Review

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

Provider Information
1 What state(s) do you collaborate with this provider?
2 Have patients been seen this month?
Estimated number of patients seen this month:
Why not?
3 Have you had a check-in with your collaborating physician 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 provided patient charts for your physician to review?
How many charts were provided?
Why not?
6 If charts have been sent to your physician for review, have you kept a log for tracking purposes of which charts were sent?
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.