Telehealth Funding Application

Thank you for your interest in partnering with MHS on a school-based telehealth initiative in your community. In order to begin the process, the provider and school system must already have a relationship where both parties are interested in exploring the opportunity of establishing a school-based telehealth clinic.

If awarded funding, it is in agreement that:

All marketing and educational materials specific to the school-based telehealth clinic will be co-branded with provider, school, and MHS logos
The following data will be provided to MHS: total number of users, number of visits by type/diagnosis, patient satisfaction, and parent satisfaction
The provider will partner with MHS to host two Healthy Celebration events (focused on well child visits) per school year
The school will participate in MHS’ Adopt-A-School program each school year
The school will display donated plaque within school-based telehealth clinic/front office

Please fill out the following information entirely in order to have your application considered.

Name of school system *

Name of school where equipment will be housed *

County school system is in *

Student enrollment within school system *

Student enrollment within school where equipment will be housed *

Free and reduced lunch rate percentage *

Number of school nurses that work for the school system *

Number of school nurses full time *

Number of school nurses part time *

Please select all of the desired services to be provided * Primary care Behavioral health

Is the partnering provider already conducting telehealth *

Contact first name *

Contact last name *

Contact title *

Contact email *

Contact phone number *

Last Updated: 01/22/2021