NARBHA Documentation of Provider Orientation
on Use of Video Equipment for Telemedicine

Behavioral Health Medical Practitioner Name: ________________________________________

Network Provider (agency): ________________________________________________________

 Orientation conducted by:

____ Review of NARBHA online web-based orientation OR

____ Sara Gibson, MD, NARBHA Telemedicine Medical Director in person

 Behavioral Health Medical Practitioner, please sign and date when orientation is completed and:

1. Ensure that this documentation is placed in your personnel record.

2. Send a copy with your quiz results to NARBHA, attn. Telemed Staff:
Fax: (928) 774-566
Email: telemed@narbha.org
Mail: 1300 S Yale Street
Flagstaff, AZ 86001

Attachments (online)

1. NARBHA’s Provider Policy 10.10, “Clinical Telemedicine Services”
2. NARBHA Provider Policy 3.11, “General and Informed Consent to Treatment”
   • Informed Consent to Participate in Telemedicine Services, PM Form 3.11.2
   • Informed Consent to Record Participation in Telemedicine Services, PM Form 3.11.3
   • Telemedicine Allowable Codes
3. Informed Consent for Psychiatric Medication Treatment, modified for telemedicine,
   use PM 3.15.1 TMED

Click here for the full list of links to clinical telemedicine policies, forms, and resources.