Connect Health Information Network (ConnectHIN) Marketplace Participation Initial Request

ConnectHIN facilitates collaborative opportunities among Provider/Prescribers and licensed entities, promoting incident-to billing arrangements and reciprocal ancillary benefits, including patient relationship generation and other benefits. Please submit this initial participant information to start the process.

Name * Title First Middle Last Suffix
Entity Name (Practice or Group Name) *
Type of Organization *
Physicians (MDs, DOs) and their subspecialties Nurse Practitioners (NPs) Physician Assistants (PAs) Clinical Nurse Specialists (CNSs) Dentists (DDS, DMD) Podiatrists (DPMs) Optometrists (ODs)
Specialty if Physicians (MDs, DOs) and their subspecialties is selected
Taxonomy
National Provider/Prescriber/Prescriber Identifier (NPI) *
Primary Contact Name (if different from the Provider/Prescriber) *
Phone * - ### - ### ####
Email *
Fax Number (If Available) - ### - ### ####
Practice Service Location(s)
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
State(s) Licensed (all states where the Provider/Prescriber holds a license) *
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Service Area (geographic region served)

Connect Health Information Network (ConnectHIN) Marketplace Participation Initial Request

Connect Health Information Network (ConnectHIN) Marketplace Participation Initial Request

Practice Service Location(s)