Technology Vendor Contact Us

We appreciate your interest in Surescripts certification and look forward to speaking with you. The first step is to complete the following form.

First Name:
Last Name:
Title:
Company:
Telephone:
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Email:
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Address:
City:
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Zip Code:
Area of Focus:
Company Web site:
Legal name of entity as it appears on incorporation documents:
Type of legal entity (corporation? LLC?):
State of incorporation:
Could you briefly describe your company and your product(s)?
Please list the name and version of the application you intend to certify with Surescripts:
Is the product that you want to certify in development and if so when you do expect to launch it?
Are you planning on working with a third party to connect to the Surescripts network?
How long has your company sold the application?
Is there an additional cost to the end user for electronic prescribing?
On a scale of 1 to 5 with one being the lowest and 5 being the highest, how would you rate Surescripts certification/implementation as a priority for your product/organization?	12345
Is the application client/server based or ASP based?
What is your target “go live” date (i.e., e-prescribing)?
Will your rollout strategy be regional or national in focus? If regional, where specifically?
Other comments or questions: