Medical Doctor Interstate Telehealth Registration Application

Name:
Submission Date:	10/12/2026
Page 1
Applicant Information

Applicant Information


First Name	Middle Name	Last Name	Suffix
Maiden Name	Alternate Name(s):
Date of Birth	Social Security Number
Gender	Hair Color	Eye Color

Height (Feet and Inches):


Feet	Inches	Weight
Identifying Marks

Please upload recent photograph
The photograph must be:

Studio quality

A close-up front view of head and shoulder areas only (not a profile)

Of yourself only (group photographs will not be accepted)

Taken within the last twelve months

Please provide the approximate date this photograph was taken:

Click here for recommendations on uploading files.

Proof of Identity

Please upload a clear and legible copy of your government-issued identity document bearing your legal name and date of birth. Accepted documents include a passport, birth certificate or certificate of naturalization.*

Click here for recommendations on uploading files.

Click here to view the recently uploaded file.

Medical Doctor Interstate Telehealth Registration Application

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