Oregon PDMP Integration Request Form

Completing this form is a requirement for PDMP Integration. Additional legal documents must be signed and returned as well before your request will be processed.

Additional PDMP Integration required materials and information can be found here.
Questions? Contact pdmp@hitcommons.org

Question Title

* I have the authority to make decisions for my organization about PDMP Integration:

Yes

Question Title

* Business Information

Company Name *

Address *

City/Town *

ZIP/Postal Code *

NP or Tax ID

Website

Question Title

* Business type (please choose one)

Health system

Independent Hospital

Group Practice

Independent Practice

Retail Pharmacy (independent)

Retail Pharmacy (chain)

Other (please specify)

Question Title

* Please enter the number of each per your business (enter '0' if none)

Hospitals

Clinics

Hospital Pharmacies

Retail Pharmacies

Prescribers

Pharmacists

EHR-hosted sites

Question Title

* Primary Contact Information

Name

Role

Email Address

Phone Number

Question Title

* Secondary Contact Information (optional)

Name

Role

Email Address

Phone Number

Question Title

* IT Contact Information

Name *

Role

Email Address *

Phone Number *

Question Title

* Vendor Information

Vendor Name *

Product Name(s)

Product Version(s)

Vendor Contact Name

Vendor Contact Email

Vendor Contact Phone

Question Title

* Install Type

On-Premise

Cloud