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Download the Registration Form to Enroll in DHIN

Thank you for expressing interest in the Delaware Health Information Network (DHIN). Please download and complete the form in Word format below so that we can have information about you and your practice in order to get you set up as a DHIN user. Once completed, please email the form to Rhonda.Register@dhin.org.

OR   

Fill Out the DHIN Registration Form Below!

You may fill out the Registration form online as an alternative to completing the word document above.

Practice Group Name:
Date:
Address:
City:
County:
State:
Zip code:
10 Digit Org NPI:
Specialty:
Number of Clinicians:
(physicians, physician assistants and advance practice nurses)
Number of Staff:
Number of Practice Sites:

Location (towns or cities) of your other practice sites:
Please tell us about the technology you currently use (check all that apply):
Name of EMR Vendor:
Software Version:
Practice Management System:
Product Version:
Please specify:

Please tell us your account numbers for:
LabCorp:
LabCorp 2:
Quest:

Please identify a primary and a secondary contact to serve as the DHIN Administrators:
Primary Contact:
Primary Title:
Primary Phone:
Primary Fax:
Primary Email:
2nd Contact:
2nd Contact Title:
2nd Contact Phone:
2nd Contact Fax:
2nd Contact Email:

Please list the providers and their credentials (Ex: John Smith, MD) at the practice:
Provider 1 Name/CRDL:
Provider 1 NPI:
Provider 1 Specialty:
Provider 1 Location:
Provider 2 Name/CRDL:
Provider 2 NPI:
Provider 2 Specialty:
Provider 2 Location:
Provider 3 Name/CRDL:
Provider 3 NPI:
Provider 3 Specialty:
Provider 3 Location:
Provider 4 Name/CRDL:
Provider 4 NPI:
Provider 4 Specialty:
Provider 4 Location:
Provider 5 Name/CRDL:
Provider 5 NPI:
Provider 5 Specialty:
Provider 5 Location:
Provider 6 Name/CRDL:
Provider 6 NPI:
Provider 6 Specialty:
Provider 6 Location:
Provider 7 Name/CRDL:
Provider 7 NPI:
Provider 7 Specialty:
Provider 7 Location:
Provider 8 Name/CRDL:
Provider 8 NPI:
Provider 8 Specialty:
Provider 8 Location:
Provider 9 Name/CRDL:
Provider 9 NPI:
Provider 9 Specialty:
Provider 9 Location:
Provider 10 Name/CRDL:
Provider 10 NPI:
Provider 10 Specialty:
Provider 10 Location:

How did you hear about DHIN:
Name of Event:
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