Registration for EPCS Module Integration Audit of EHR

This information is needed as an initial step for testing your software product which has an integrated EPCS Module. Upon our receipt of this completed form, you will be contacted by our EPCS Client Services staff and receive more detailed information.

EPCS Audited Module Solution to Integrate into your EHR product (* fields are required.)

Module Vendor - Company Name(*)
Module Vendor field is required

Type of Integration

Please indicate what type of ePrescribing integration.

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Certification Service Requested

Please indicate what type of service you are requesting.

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EHR Company Info (* fields are required.)



This is your company information
Company Name(*)
Company Name is required

Address 1(*)
Address is required

Address 2
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Address 3
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City(*)
City is required

State(*)
State is required

Zip Code(*)
Zip Code is required

Phone(*)
Phone is required

Company URL(*)
Company URL is required

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Product Used by What Type of End-User(s)



Please indicate what type of End Users you target with your product.
Please indicate what type of End Users you target with your product

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Product Certification Status

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If Certified by DGI please provide your Certification Number:
Certification Number
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Product Information (* fields are required.)



Please provide the name of your product
Product Name(*)
Product Name is required

Product Version No.(*)
Product Version No. is required

Product URL
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Notes
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Availability (* fields are required.)



When do you want to schedule the integration audit review of your product? The audit will review that your product meets requirements for e-Prescribing Controlled Substances?
Notes
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Administrative Contact (* fields are required.)



This person is the primary point of contact
First Name(*)
First Name is required

Last Name(*)
Last Name is required

Title(*)
Title is required

Phone(*)
Phone is required

ext
Phone is required

Email(*)
Email is required

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Additional Contact Information



Accounts Payable Contact (optional)

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First Name
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Last Name
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Title
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Phone
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Fax
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Email
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Marketing/Press Contact (optional)

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First Name
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Last Name
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Title
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Phone
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Fax
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Email
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Product Manager Contact (optional)

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First Name
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Last Name
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Title
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Phone
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Fax
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Email
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Technical Contact (optional)



This person is required to operate and support your product during the execution of the interoperability test.

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First Name
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Last Name
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Title
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Phone
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Fax
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Email
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