NC HealthConnex Bidirectional Interface Confirmation Form 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 Organization Contact Address Address 2 City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Organization NPI Number Provide your organization's 10-digit national provider number. Participant Account Administrator Information Name Phone Number Email HIEA will direct further communication to this email address. Electronic Health Records Vendor Information Vendor Name Contact Email
NC HealthConnex Bidirectional Interface Confirmation Form 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 Organization Contact Address Address 2 City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Organization NPI Number Provide your organization's 10-digit national provider number. Participant Account Administrator Information Name Phone Number Email HIEA will direct further communication to this email address. Electronic Health Records Vendor Information Vendor Name Contact Email
