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Clinician Registration for e-Prescribing Access
Please complete this form to provide the credentials and practice details we need to enable e-prescribing on our platform.
If you intend to prescribe controlled substances, you will be required to complete an
Electronic Prescribing of Controlled Substances (EPCS)
identity-proofing and credentialing process after registration.
All fields marked with * are required; optional fields may be left blank.
* Indicates required question
First Name
*
Enter your legal first name as it appears on your professional documents.
Your answer
Last Name
*
Enter your legal last name as it appears on your professional documents.
Your answer
Degree Suffix
Example: MD, DO, PhD, PsyD, PMHNP, LCSW, LMFT. Leave blank if none.
Your answer
NPI
*
Enter your 10-digit National Provider Identifier (NPI).
Your answer
Email Address
*
This email will be used for
system access, credentialing, identity proofing and LAC
. Make sure it’s correct
Your answer
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