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

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