Arkansas eRx Application

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If you are an Arkansas Medicaid provider and are interested in implementing e-prescribing in your office, please complete the online application for assistance.

When your application is received, the primary contact noted in your response will be contacted and an evaluation appointment will be scheduled.

Practice Name: *

Phone Number: *

Fax Number: *

Physician Name & Medicaid ID Number: *

Office Manager/Administrator Name: *

Street Address: *

Street Address Line 2:

City:

State:

Postal/Zip Code:

E-mail: *

How many physicians at your practice site? *

What is your practice's specialty? *

If "other" please explain:

How many sites does your practice currently have?

What is the percent of your practice's volume of Medicaid patients?*

Are you are interested in implementing ePrescribing? *

If "Yes", when do you plan on implementing?

Do you currently have an automated practice management system in your office?*

If "Yes", what is the name of the product?

Do you you currently have an electronic medical record (EMR) system implemented? *

If "Yes", what is the name and version of the product?