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 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.