Request for Support

Provider Survey

Are you a Healthcare Organization or a Hospital in need or preparing for COVID surge support?

If you are a healthcare organization or a hospital in need of COVID surge support and meet the NETCCN Support requirements listed below, please click the button below and fill out our survey.

NETCCN Support Requirements:

  • Waiver of state licensure requirements (i.e. cross state licensure for telemedicine) by law or executive order;
  • A local clinical, IT, and administrative champion willing and available to help solve problems together with the NETCCN partner. These individuals must complete demographic survey information for the hospital and be able to define/negotiate requested services;
  • Rapid disaster privileging for NETCCN remote experts (doctors, nurses, respiratory therapists, as needed);
  • Availability of personal or facility purchased mobile devices (cell phones or tablets); in some cases, a web interface can be used on a laptop or desktop computer;
  • Have sought or is seeking assistance through local and state public health departments to address critical care surge needs;
  • An acknowledgement that the credentialing office will accept NETCCN's standardized disaster privileging packets.


  1. Validate that you have a PDF reader with form-completion features. Need a PDF Reader? Download a PDF Reader by clicking here.
  2. Download the "NETCCNRequestSupportSurvey.pdf" form in pdf format
  3. Complete the PDF form and save completed survey.
  4. Email the completed survey to:
Download Request for Support Survey
Provider Survey