EHR Integration Sign-Up Application

Thank you for your interest in integrating your EHR with our state's prescription drug monitoring program.
Sign-up process is to provide us with some general information. Upon receipt of your submission, we will provide you with next-step information concerning the contractual process and on-boarding steps needed to activate your system.

Please complete the form even if your state is not currently participating. This can change quickly and we will let you know the status of your state. We look forward to working with you!
(*) Marked fields are mandatory to submit the request in our database


Must be min 2, max 15 characters
Must be 20 digit alphanumeric characters