SureScripts

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Home > Pharmacies > Refer a Prescriber

Find out which pharmacies are activated for e-prescribing in your area.

Thank you for your interest and efforts in encouraging the prescribers to establish a direct electronic connection with your pharmacy and others in your area. Please use this form to refer a prescriber, or practice staff member, to receive follow-up information from us to help establish this connectivity.

NOTE: We are not able to send this information unless you have first talked with the person you are referring and received their permission to accept follow-up information about electronic prescribing from SureScripts®, operator of the Pharmacy Health Information Exchange™. We have provided a check box for you to acknowledge that this has taken place.

Referring Pharmacy Staff Member Information

Note: All information is required

Pharmacy Name:
If Other/Independant, please specify:
First Name:
Last Name:
I have spoken with this prescriber and they have requested more information from SureScripts.
Practice Contact
First Name:
Last Name:
Position:
Postion (Other):
Practice Name:
Address:
City:
State:
Zip Code:
Telephone:
Fax:
Email:
Send follow-up information via:	Email Fax
Practice Specialty:
No. of Prescribers in Practice:

Comments: