Provider Network Want to Join the TeleradDirect Provider Network? Complete our provider questionnaire to start the application and vetting process. Step 1 of 5 20% General InformationCompany Name*Your Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* How long in business?* Business DetailsDo you have a defined niche or area where you provide superior service or quality?*What attributes or strengths (in bullet fashion) define your service or differentiate you from other providers?Define your ideal client(i.e., Hospitals under 100 beds in rural area, with zero telerad experience, with less than five in-house radiologists, etc.)Do you have targeted areas/goals for new business or expanding into new areas? Your OrganizationHow many radiologists or RVUs do you utilize per month?What states are you licensed and providing service?*Please provide coverage days and times for each states.Do you provide 24/7/365 coverage?* Yes No Are you providing sub-specialty reads?* Yes No If yes, what subspecialties?*What modalities are you providing or can provide reads?* Turnaround TimesProvide the Turnaround times you provide when setting expectations for your customers for each of the following.Stoke Protocol (if provided)STAT (if provided)Urgent (if provided)Routine (if provided) ReferencesDo you have any testimonials or promotional items that we could utilize in gaining appropriate interested clients? Yes No Please provide testimonials.URLThis field is for validation purposes and should be left unchanged.
