Prior to submitting this form; please ensure that both YOU and your DESIGNEE(S) have also completed the PDMP User Access and Training Acknowledgement Form.
Designator = a prescriber or pharmacist who wishes to grant access to an individual to access the Nebraska PDMP on their behalf.
Designee = an individual that has been granted access the Nebraska PDMP on behalf of a prescriber or pharmacist.


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* 1. Designator First Name

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* 2. Designator Last Name

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* 3. Designator Professional State License Number

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* 5. Designator OPTUM ID (the user name that is used when accessing the Nebraska PDMP).  If you do not know your OPTUM ID, please go to www.nehii.org/hie and select "My Account'.

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