Prescription Monitoring Program: Designee Registration

Please complete and submit the following form. We will use the information to verify your identity and the authenticity of your access request. We will contact you by e-mail. License status will be verified by using the applicable state's professional license lookup services. Submitted information will remain confidential.

For verification purposes, all information is required and will be kept confidential.
Designee Information
All communications will be sent to this email address, including information that will help you recover your ID or password.
Please enter your email address again to help ensure accuracy.
8 to 32 characters with at least 1 number and 1 upper and lower case letters. Do NOT use your email password.
Please re-type the password to help ensure accuracy.
() - -
Enter in any format, the day and time we would most likely be able to reach you by phone at your practice.
ex: 123 456789

If you select "I do not agree", please call (217) 524-1311.

Note: Please allow 1-2 business days for application processing. Your account will not be activated until we have contacted you by phone.