Request For PMPNow Connection

Name of software product

Is your software product an Electronic Health Record System?

Is your software product an ePrescription Module?

Is your product Pharmacy Management Software?

Are you in good standing with the ONC on the Certified Health IT Product List?

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 IL PMP database information?

How many Pharmacists would access the IL PMP database information?

What connection protocol are you interested in using?

Please provide the best contact information for our team

Additional notes

Please make sure all fields with a red asterisk(*) are completed.

Connection to the IL PMP is based on the responses above. This will not limit any registered and licensed practitioner, prescriber, or pharmacist from being able to view the information directly from the Illinois PMP site at www.ilpmp.org.

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Thank you for using the ILPMP.

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