PMPnow Vendor Connection Request

What is the name of the product?

What type is the product?

Electronic Health Record System/ Electronic Medical Record System

ePrescription Module

Office of the National Coordinator Certified Health IT Module

Pharmacy Management Software

Other

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

Yes

No

Not Applicable

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

Yes

No

Not Applicable

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?

Additional Notes