Telemedicine · Department Of Health

Health Facility Services

NJ Health

1Telemedicine Form
2Payment & Certification
3Review & Submit
4Print(Summary)

Application for Registration of Telemedicine / Telehealth Organizations

Organization / Entity information

EIN (Employer / Tax ID)

*

Entity name

*

Enter street address for the applicant entity main office location.

*

Address not found ?

Street address

*

Suite/Floor

*

City

*

State

*

Zip

*

Entity representative information

First name

*

Middle name

*

Last name

*

Representative title

*

Representative email address

*

Phone

*

Doing business as (DBA) information

Doing business as(DBA)

*

Registered agent information

Registered agent name

*

Registered agent New Jersey street address

*

Address not found ?

Street address

*

Suite/Floor

*

City

*

State

*

Zip

*

Registered agent email address

*

Phone

*

Certified by

*

Certified on behalf

*

Certified onbehalf

*