Get Teladoc Provider Application

The Teladoc Provider Application is a critical document for healthcare professionals seeking to join the Teladoc network. This guide will help you navigate the online filling process, ensuring you provide all necessary information accurately and efficiently.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the personal and practice information section. Ensure you include your name, U.S. citizenship status, social security number, place of birth, specialty, home address, and contact information clearly.
3. Next, under the languages section, list any languages other than English in which you are fluent and wish to conduct consultations.
4. Provide your Medicare and NPI numbers. If applicable, indicate whether you are registered as a provider with Medicaid, and list your Medicaid registration numbers along with the corresponding states.
5. Fill in your education and training details. Include your college or university information, degree obtained, major, and dates of attendance. If you have postgraduate education, repeat the fields appropriately.
6. When completing the professional license/certification section, provide details for each medical/professional license, including the issue date, state of licensure, license number, type, and expiration date.
7. Complete the professional reference section by listing two professional references who can attest to your qualifications. Ensure you include their contact information and relationship to you.
8. Outline your work history for at least five years, detailing each employer, job title, contact information, and the period you were employed there.
9. Respond to all professional information questions accurately, ensuring you provide any necessary documentation for affirmative answers.
10. Finally, review all entered information for accuracy. Once everything is complete, save your changes, and then you can choose to download, print, or share the form.

Start your application process online today and take the first step toward becoming a Teladoc provider.