Request for Information About E-Prescribing

Fill in all of the fields below and then click the Submit button. We will contact you with more information about upcoming e-prescribing initiatives for Illinois providers. Thank you for your interest!

An asterisk (*) indicates a required field.

*First Name:
*Last Name:
*Practice Name:
IPA Affiliation (if applicable)
*Primary Contact Name
*Primary Phone Number / /
Additional Information/Comments