Practice Enrollment Form

Wed, 10/10/2012 - 09:21 -- Anonymous (not verified)

Enroll in DHIN:  Save time, save money and provide better care.

By completing this form your practice will be on its way. Once we have received the form the DHIN Provider Relations Coordinator will contact you to get your staff set up with DHIN. If you have any questions about this form or DHIN enrollment, please contact us at (302) 678-0220 or by email at newuser@dhin.org.

Download the Word version of the DHIN Enrollment Form here.

Section 1 - Group/Practice Contact Information:
Please select one
(Please include these providers: MD, DO, OD, DDS, DPM, DC, PA, and APN)

The minimum requirements for DHIN are:

  • High-speed Internet (example: DSL, Cable, Satellite, T1)
  • Windows XP, 2000 or greater
  • Internet Explorer 7.0 or greater
  • Adobe Reader 7.0 or later
  • Adobe Flash Player 8.0 or later
  • Current updated antivirus software
  • Laser Network Printer
(If applicable)
(If applicable)
Check all that apply
Please provide the practice account numbers for:
Please provide the practice account numbers for: