DSMES via Telehealth – Originating Site Clinic Application

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Application for clinics interested in partnering with Well-Ahead Louisiana and a DSMES provider to establish DSMES via Telehealth connection in their clinic.

Email *

Facility Name *

Facility Type *

Facility Parish *

Primary Contact Name *

Primary Contact Email *

Does the clinic have a staff member who can serve as Champion for this project? *

Yes

Maybe

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