Submit a request

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Please choose a request type below

Your email address

Subject

iPrescribe User(optional)

Please provide specific details so that we may provide faster support.

State

Client Type

Termination Reason(optional)

Please provide reason for termination

PDMP Vendor(optional)

Gateway State Funded(optional)

Enhanced State Funded(optional)

Enhanced Report(optional)

Licensee Name(optional)

Licensee Organization Name

Date of Application to State(optional)

Estimated Go-Live Date(optional)

Date your organization is expecting to go live with PDMP

Client Mnemonic

Practice Username, Mnemonic, Source Organization ID, or Office Key

Number of Users(optional)

Practice Username or Name of Affiliate(optional)

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)

NPI(optional)

Please enter 9 digits for your NPI number

Account Username(optional)

First Name(optional)

Last Name(optional)

Email(optional)

Address 1(optional)

Address 2(optional)

City(optional)

State Code(optional)

Zip Code (optional)

Licenses Purchased(optional)

Licensee Website(optional)

Your organization's website. If you do not have one, please use http://example.com

Customer Number(optional)

Organization Type(optional)

OHP Username(optional)

Modality(optional)

Medical License Number(optional)

Locations(optional)

States for which you are requesting Data Sharing

Number of Office Locations(optional)

Number of Hospital Locations(optional)

Attachments(optional)

Add file or drop files here