PDMP Enrollment Request

Please complete all sections below to submit your request to Kareo to complete a PDMP integration with DrFirst on your behalf. You may be prompted to upload the required documents so be sure to have those ready.

Kareo Customer Information

Kareo ID *This question is required.

Kareo Account Name *This question is required.

Contact Name *This question is required.

Contact Email Address *This question is required. This question requires a valid email address.

Contact Phone Number *This question is required.

Practice Information

Practice Name *This question is required. This should match the practice name that is in the Kareo platform.

Practice Street Address *This question is required.

Practice City, State, Zip *This question is required.

Practice Fax Number *This question is required.

Practice NPI *This question is required. This question requires a valid number format.

State Board License Number (if applicable)

License State Board (if applicable)

DEA Number (if applicable)

Enrollment Information

Which state's PDMP are you requesting to enroll with? *This question is required.

Enter your OneHealthPort ID *This question is required.

How many providers are you requesting to enroll? *This question is required. This question requires a valid number format.