Telehealth Originating Site Facility Fee Form

Streamline Your Telehealth Facility Fee Billing with Paperform

Medical practices offering telehealth services need accurate documentation for originating site facility fee reimbursement. This Telehealth Originating Site Facility Fee Form helps healthcare providers capture all required information—from geographic eligibility to technology requirements—ensuring compliant billing submissions to insurance carriers.

Built for Modern Healthcare Workflows

Whether you're a rural health clinic, a federally qualified health center (FQHC), or a medical practice expanding telehealth access, this template helps you document the originating site details required by Medicare, Medicaid, and private insurers. The form includes conditional logic to verify geographic eligibility based on location type, captures essential technology specifications, and collects patient and provider information in one streamlined workflow.

With Paperform's calculation engine and conditional logic, you can automate eligibility checks and route submissions to your billing department based on insurance type or service location. Connect this form to your practice management system, EHR, or billing software using Stepper—Paperform's AI-native workflow builder—to automatically update patient records, notify billing staff, and track facility fee claims without manual data entry.

Why Healthcare Providers Choose Paperform

Paperform is trusted by over 500,000 teams worldwide and is SOC 2 Type II certified, making it a secure choice for healthcare administrative forms. While not HIPAA-compliant for protected health information, this template is perfect for billing documentation and administrative workflows that support your telehealth program.

The form's professional design can match your practice's branding, and submissions can trigger automated workflows through Stepper or integrate directly with tools like Google Sheets, Airtable, or your existing practice management platforms. Plus, with AI Insights, you can analyze submission patterns to identify common billing issues or geographic trends in your telehealth services.