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* 1. First Name

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* 2. Last Name

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* 3. Professional State License Number

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* 6. Last four digits of SSN*

*This field is optional and is used to verify your credential issued by the Nebraska DHHS DPH Licensure Unit under the
Uniform Credentialing Act to verify eligibility for access to the Nebraska PDMP under Neb. Rev. Stat. §71-2454.

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* 7. Primary Organization Name

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* 8. Primary Organization Phone Number (numbers only i.e. 4025551212)

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* 9. Primary Organization Email Address (your email address associated with your primary organization)

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* 10. Primary Organization Office Manager Email Address

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* 11. Personal/Preferred Email Address (the email address you would like to use for your PDMP registration if different than what was listed above)

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* 12. By checking the box below you attest to the completion of the mandatory training as described in Neb. Rev. Stat. §71-2454.

If you have not completed the mandatory training; please click here to review the training video.  The video will open in a new browser window; allowing you the opportunity to come back and complete the form after watching the training video.

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* 13. Action

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* 14. Do you provide patient treatment at any additional organizations where your EHR or pharmacy software log-in is different than what is used for your primary organization?

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