EMR Interface Request Form
Request Type
*
Please Select
EMR Interface Request
Cancel an In Progress Interface Implementation
Cancel a Live Interface
Show Form
Laboratory Information
Please Choose a Lab
*
Please Select
Accu Reference Medical Lab
Platinum Diagnostic Laboratory
Laboratory Name
*
Laboratory Contact Name
*
Laboratory Contact Name 2
Laboratory Contact Name 3
Laboratory Contact Phone
*
Lab Contact E-mail
*
You will receive a confirmation email for your request at this email address
Practice Information
Practice Locations (Click on "Save" after you enter the practice information)
*
Physician Account Numbers (Click on "Save" after you enter the physician information)
*
EMR Interface Request
EMR Company Information
EMR Company
*
Please Select
Other than below
Adapta Med
ADS
Allscripts
Amazing Charts
Aprima
Arete
Athena Health
AVS Medical
AZALEA
Bizmatics
Care Cloud
Care360
Centricity
Cerner
Change Healthcare
Claim Power
Clover Health
Connexin
Conxit
Criterions
Cure MD
DHIN
Digi
Doc Comply
DOC-TOR
Dr-Solutions
eClinical Works
EDE
EHI
EHR
Elchay
Elation
Ellkay
E-MD
Emdeon
E-Transmedia
EZ Practice
Glenwood Systems
Greenway
Guaranteed IT Solutions (GITS)
Half Penny
Health Fusion
Hello Health
HEALTH GORILLA
ICANOTES
INSYNC
Integrity Med System
Ipatient Care
LabSoft
Liaison
Lightening Step
Mckesson
MDLand
Mdol
Medent
Medgen
Medical Business Sys
Medical Mastermind
Medios
Medi-Tab
Methasoft
MicroMD
Microwize
MTBC
Next Gen
Office Ally
Office Practicum
OpenText/PCC
Optum Insight
Practice Fusion
Practice Partners
Praxis
PULSE
RXNT
Sigmund
Sevocity
SOAPware
Spring Charts
STI
Sunrise
Tangible Solutions
Verify EMR
Virtual Officeware
WRI Health
EMR Company
*
Please Select
Other than below
eClinical Works
Medgen
Please Upload the Practice Fusion Bound Email
*
Upload a File
Cancel
of
New EMR Company Name
*
REPLY EMAIL EMR
EMR Contact Name
*
EMR Contact E-mail
*
EMR Contact Phone
*
Interface Details
Interface Type
*
Please Select
Uni-Directional
Bi-Directional
Demographic Bridge
Will AOE's be required?
Yes
No
Will insurance mapping be required?
Yes
No
Cost of EMR Interface
Monthly Maintenence
ALL Requests
Comments
Requester Name
*
Cancellation Type
Assigned to
Reply Emails
Submit
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