NC HealthConnex Form Page - Smartlink Health Solutions

Are you interested in connecting to NC HealthConnex?

Complete the form below to have a representative contact you within 2-3 business days.

First and Last Name *

Title *

Phone Number *

Email *

Legal Practice Name *

City/County *

How many providers are in your practice? *

What type of insurance do you accept? *

Were you previously connected to the HIE? *

Yes

Have you filed a Participation Agreement with NCHIEA? *

Yes, Submit Only

Yes, Full Participation

No, I have not filled out a Participation Agreement

What is the name of the EHR that you use? *

If you have an EHR, what is the operating environment? *

If you don't have an EHR, do you have a Practice Management or Billing System? If so, please provide the name of the product. *

Thank you for your interest in connecting to NC HealthConnex. A member of our support team will contact you within two to three business days.

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