To view this list as a PDF please click HERE.
To speed up registration, please have the following information available to complete registration. All items below are Required unless otherwise indicated.
PRACTICE DETAILS:
Practice Name
Practice Address
Practice Phone
Practice Fax
Website Address (if applicable)
Practice Email
Organization / Practice NPI #
Practice EIN / Federal Tax ID
Primary Contact Name
Primary Contact Email Address
IT DETAILS:
Current Practice Management Software (PMS/EHR)
Practice Management Software Version #
IT Company Name
IT Contact Phone
IT Contact Email
DETAILS FOR EACH PRESCRIBER/DOCTOR:
Name (as it appears on driver’s license)
Email Address
NPI #
State Medical/Dental License #
DEA #
Upload DEA details for each prescriber/doctor (optional)
DETAILS FOR EACH ADDITIONAL USER:
(Non-prescribing users may ‘stage’ a prescription but only the actual prescriber may ‘transmit’ the prescription)
Name (as it appears on driver’s license)
Email Address
Role/Title
Questions? Call 888-810-7706 or submit a request HERE