Patient Education Brochure Order Form

Submitted by aljohnson on Fri, 08/06/2021 - 09:56

Heath care providers can order trifold brochures to educate patients about the benefits of participating in NC Health Connex, the state health information exchange. The brochures also have information about patients' right to opt out of sharing their medical information.

See the patient education brochure.

Complete the following form to order brochures from the N.C. Health Information Exchange Authority. You can place an order to ship brochures to up to three different practice locations. Note that brochures come in packages of 100.

Indicates required field

Contact Information

Practice Name

First Name

Last Name

Phone

Shipping

Address

Address 2

City

State

ZIP Code

Packages Requested

Each package contains 100 brochures. You must select one of the following options to submit the form.

English

Spanish

Would you like to order brochures for another practice?

Yes

Second Order

Contact Information

Practice Name

First Name

Last Name

Phone

Shipping

Address

Address 2

City

State

ZIP Code

Packages Requested

Each package contains 100 brochures.

English

Spanish

Would you like to order brochures for another practice?

Yes

Third Order

Contact Information

Practice Name

First Name

Last Name

Phone

Shipping

Address

Address 2

City

State

ZIP Code

Packages Requested

Each package contains 100 brochures.

English

Spanish

This question is for testing whether or not you are a human