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eCareConnection Information Request


GROUP INFORMATION
Group Name
List Names of Group Physicians
Desired Program Type (check one) Basic eCareConnection
EHR Lite
Both
Name/Version of Current Electronic Medical Record (EMR) System
Is your EMR certified for Meaningful Use? Yes
No
Name of Current Practice Management (PM) System
Lab Companies Used by Practice
(Lab Corp, Quest, SLEHS, etc.)
General Comments/Questions
OFFICE CONTACT
First Name
Last Name
Phone
Email