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Terms of Service:
*
I have read and agree to the terms and conditions listed here to be listed on FlexMedStaff website.
This needs to be editedf or telemed. Please complete the form below to allow FlexMedStaff to place you on the website/platform as a source for the general population too contact you. There is an annual fee that must paid separately to activate and continue your account with FlexMedStaff. FlexMedStaff, LLC is to be held harmless in the event any action is brought against an individual. patient or facility associated with the use of this platform/website or the interaction between the practitioners and patients or general population. It is the sole responsibility of the users to research and verify the practitioners and users of the platform. FlexMedStaff, LLC only provides a job-board only. FlexMedStaff is not responsible for billing or collection of payment from users other than the practitioners that chose to be listed on the platform. Your information here will not be sold or used with 3rd party vendors.
Name of Contact Person
*
First
Last
This is for internal purposes only. This information will not be shared publically.
Direct Email of Contact Person
*
This is for internal purposes only. This information will not be shared publically.
Phone Number of Contact Person
*
This is for internal purposes only. This information will not be shared publically.
NPI Number
This is for internal purposes only. This information will not be shared publically.
Primary State Medical Licenses to Practice Medicine
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia (DC)
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
This is for internal purposes only. This information will not be shared publically.
License number of primary state medical license
This is for internal purposes only. This information will not be shared publically.
Information below will be placed the Physician Telemedicine directory.
Full Name of Practitioner to be listed on Website
*
First
Last
Email Address to be listed on Website
*
Profession
*
MD
DO
List you primary specialty as an MD/DO
*
List all the specialities
Second Choice
Third Choice
If you have a 2nd specialty or subspecialty please put it here...
List of specialities here
Second Choice
Third Choice
If you have a 3rd specialty or subspecialty please put it here..
List of specialities here
Second Choice
Third Choice
Upload a professional picture/image of yourself.
*
Click or drag a file to this area to upload.
Upload a short video (1-2 minutes) of yourself introducing your services.
Click or drag a file to this area to upload.
If you are unable to upload video then please provide URL so that the video can be linked to website.
If you can not upload video then please provide URL of website (ie: Youtube link)
Example: https://flexmedstaff.com
Description of yourself and your services
*
Enter a detailed description of the position.
Provide your personal website / URL if applicable
Example: https://flexmedstaff.com
State Medical Licenses to Practice your Profession (you can select multiple)
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia (DC)
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Do you prescribe mental heath medication?
*
Yes
No
Do you accept credit card?
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Yes
No
Do you accept private commercial insurance?
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Yes
No
Do you accept Medicare?
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Yes
No
Do you accept Medicaid? (copy)
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Yes
No
Languages Spoken (you can select mutlple)
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English
Spanish
French
German
Latin
Portuguese
Other
List other languages spoken
What calendar service do you use?
*
Calendarly
iCal
Microsoft Outlook
Google Calendar
Other
What calendar service do you use if it is not listed above?
*
Submit
Facility registration for FlexMedStaff is currently in process of development, so please contact us directly for additional questions and registration details at Support@FlexMedStaff.com
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