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We appreciate your interest in SureScripts. Please take a moment to complete the following form. We look forward to talking with you about the benefits of becoming a SureScripts Certified Solution Provider™. To speak with an Electronic Prescribing Specialist, please dial 1-866-RxReady (797-3239) and press '5'.
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| First Name: |
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| Last Name: |
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| Title: |
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| Company: |
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| Telephone: |
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| Fax: |
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| Email: |
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| Re-Enter Email: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Area of Focus: |
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| Company Web site: |
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| Legal name of entity as it appears on incorporation documents: |
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| Type of legal entity (corporation? LLC?): |
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| State of incorporation: |
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| Email Contact for Sales Inquiries: |
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| Could you briefly describe your company and your product(s)? |
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| Please list the name and version of the application you intend to certify with SureScripts: |
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| Is the product that you want to certify in development and if so when you do expect to launch it? |
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| Who will you be primarily marketing your product to? |
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| If Other, please specify |
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| What prescribing functionality will your system include (select all that apply): |
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| How many physician users (or clinics) are currently contracted? |
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| How many physician users (or clinics) are expected to be contracted in the next 12 months? |
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| Of your current physician customers (if applicable), what percentage use your software to fax and or print prescriptions? |
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| What type of application will you be certifying? |
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| If Other, please specify |
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| How long has your company sold the application? |
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| Is there an additional cost to the end user for electronic prescribing with pharmacy connectivity (i.e., SureScripts connectivity)? |
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| On a scale of 1 to 5 with one being the lowest and 5 being the highest, how would you rate SureScripts certification/implementation as a priority for your product/organization? |
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| Will you implement XML or EDIFACT? |
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| How is the application deployed and utilized? |
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| If Other, please specify |
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| Is the application client/server based or ASP based? |
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| What is your target “go live” date (i.e., e-prescribing with pharmacy connectivity)? |
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| How many providers (clinics) will 'go-live' in the first three months after certification? |
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| Will your rollout strategy be regional or national in focus? If regional, where specifically? |
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| Other comments or questions: |
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