SAMPLE COURSE

Thank you for signing up for the OneTouch EMR FREE Plan offered through Lake Health Alliance, Inc. In order to get you set up properly, please take a moment to complete the information needed below.

[uacf7-row][uacf7-col col:6] Are you migrating to OneTouch from another EHR? (Required)
—Please choose an option—YESNO [/uacf7-col][uacf7-col col:6] Current EHR?
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] First Name (Required):
[/uacf7-col][uacf7-col col:6] Last Name (Required):
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] Your email (Required):
[/uacf7-col][uacf7-col col:6] Your phone # (Required):
[/uacf7-col][/uacf7-row]

Your Title (Required):

Name of Practice (Required):

Practice Address (Required):

[uacf7-row][uacf7-col col:4] City (Required):
[/uacf7-col][uacf7-col col:4] State (Required):
[/uacf7-col][uacf7-col col:4] Zip Code (Required):
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] Website Address (if applicable):
[/uacf7-col][uacf7-col col:6] Practice Specialty (Required):
[/uacf7-col][/uacf7-row]

In order to get the provider setup for ePrescribing, the following basic information is required.

[uacf7-row][uacf7-col col:6] First Name of Provider (if different from above)
[/uacf7-col][uacf7-col col:6] Last Name of Provider (if different from above)
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] Title of provider (select from drop down):
—Please choose an option—MDDODCDPMDDSPhDPANP [/uacf7-col][uacf7-col col:6] NPI#:
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] License#:
[/uacf7-col][uacf7-col col:6] State:
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] DEA#:
[/uacf7-col][uacf7-col col:6] NADEAN #:
[/uacf7-col][/uacf7-row]

[uacf7-row][uacf7-col col:6] Provider's Cell Phone:
[/uacf7-col][uacf7-col col:6] Provider's email address:
[/uacf7-col][/uacf7-row]

The Provider's information will be submitted to OneTouch EMR. They will contact the provider directly to collect additional information.

If you would like to have your lab integrated into OneTouch EMR, please provide the following information.

[uacf7-row][uacf7-col col:4] Name Of Lab:
[/uacf7-col][uacf7-col col:4] Your Lab Account #:
[/uacf7-col][uacf7-col col:4] Approximate # of lab orders submitted each month:
[/uacf7-col][/uacf7-row]

If your lab request is with Quest Diagnostics, you may stop here. If it's with any other lab, please continue. PLEASE NOTE: IN ORDER TO PROCESS ANY REQUESTS, THE REMAINING INFORMATION MUST BE INCLUDED.

[uacf7-row][uacf7-col col:4] Name of Lab Rep:
[/uacf7-col][uacf7-col col:4] Phone number of Lab Rep:
[/uacf7-col][uacf7-col col:4] Email address of Lab Rep:
[/uacf7-col][/uacf7-row]

Once received, we will submit to the lab/lab rep. Once approved by the lab, it may take 4-6 weeks for the new interface to be completed, and ready for use. We will contact you with any additional information needed.
If there are any additional details or information you'd like to share, please include them below. (optional)

I accept the Privacy Policy
14+1=?

Δ