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!

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*First Name:
*Last Name:
*Practice Name:
IPA Affiliation (if applicable)
*City
*State
*E-mail
*Primary Contact Name
*Primary Phone Number / /
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