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Please provide reason for termination
Licensee Organization Name
Date your organization is expecting to go live with PDMP
Practice Username, Mnemonic, Source Organization ID, or Office Key
If you are not an EPCS Affiliate please enter Practice Username. If you are an EPCS Affiliate, please enter Name of Affiliate (Name of EPCS Organization)
Please enter 9 digits for your NPI number
Your organization's website. If you do not have one, please use http://example.com
States for which you are requesting Data Sharing