NC HealthConnex Bidirectional Interface Confirmation Form

Submitted by aljohnson on Wed, 06/02/2021 - 15:00

The N.C. Health Information Exchange Authority can help determine whether your practice participates in a bidirectional exchange with a health information exchange to support care transitions. The Centers for Medicare & Medicaid requires that clinicians and groups do so to be eligible for the Merit-Based Incentive Payment System.

Submit the form below to receive confirmation of your bidirectional connection to NC HealthConnex.

Indicates required field

Organization Information

Organization Name

Address

Address 2

City

State

ZIP Code

Organization NPI Number

Provide your organization's 10-digit national provider number.

Participant Account Administrator Information

Name

Phone Number

HIEA will direct further communication to this email address.

Electronic Health Records Vendor Information

Vendor Name

Contact Email