Provider Enrollment Form for Health Portal

The following form will allow you to register for one or more of the following servces: Electronic Prescribing (e-RX), Direct Messaging (DM), Electronic Prescribing of Controlled Substances (EPCS), Electronic Prior Authorization (ePA), PatientPortal and/or Provider Complete. Please be sure to check your email inbox for a confirmation with further instructions. There is a $50/month per provider ChartMaker Health Portal fee for this service.  

If enrolling a new provider to your office's existing Provider Complete enrollment, please check off the corresponding box below as well.

Fields marked with an asterisk (*) are required:

Check the types of e-mail notifications you want sent to this address: