PMPnow Vendor Connection Request

Please use the form below to request a connection to PMPnow, the ILPMP integration. The connection approval will be determined using the responses below. Connection approval will not limit registered prescribers and dispensers from viewing prescription data at ILPMP.org.

What is the name of the product?

What type is the product?

Are you in good standing with the Office of the National Coordinator Certified Health IT Product List?

If yes, has your product ever been reprimanded or removed from the Certified Health IT Product List?

What is this product used for?

What is your client base in Illinois?

How many prescribers would access the ILPMP database information?

How many dispensers would access the ILPMP database information?

What connection protocol are you interested in using?

Contact Name:

Title:

Email:

Additional notes:

Please make sure all fields with a red asterisk(*) are completed and no special characters are used (-+=><'")

Your request submission has been receieved!
Thank you for using the ILPMP.

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