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
 
 

Business Information

Question Title

* Business Information

Business type (please choose one)

Question Title

* Business type (please choose one)

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

Question Title

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

Primary Contact Information

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* Primary Contact Information

Secondary Contact Information (optional)

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* Secondary Contact Information (optional)

IT Contact Information

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* IT Contact Information

Vendor Information

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* Vendor Information

Install Type

Question Title

* Install Type

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