Illinois RxSubmit Application
Time:
Login
Illinois RxSubmit Registration
Step 1 - Register User
Create Login Credentials
Registration Tracking Id: {{registrationRequestId}}
Primary Email Address
Why are we asking for this?
Email address is required for login and any further communication.
*
Secondary Email Address
Password
Why we are asking for this?
To login to IL PMP you need to have password.
*
Confirm Password
*
Password must meet the following requirements:
Minimum of 8 characters
Contain one upper case letter
Contain one lower case letter
Contain at least one number
Contain one special character (! @ # $ etc.)
Maximum of 72 characters
How would you like to receive your auto generated password?
*
Email
Phone
Both
Note: Phone verification is optional here as you can verify the phone number in profile page after login. In case you want to receive message in phone then please verify your phone number before registration.
Verify Role
Verify (Role and Supervisor Email)
Category
*
Select the user category
Role
*
Select the user role
{{item1.name}}
Supervisor Email Address
*
Basic Information
First Name
*
Middle Name
Last Name
*
Gender
Select gender
Male
Female
Other
Date Of Birth
*
Last 4 Digits of Your SSN
*
Cell Phone Number
not verified
verified
Select code
{{item.iso}}, (+{{item.phonecode}})
verify
Password recovery requires a cell phone that receives text messages.
Address
*
State
*
Select a state
City
*
Select a city
Other City Name
*
ZIP Code
*
Country
Professional Information
Please provide your DEA and NPI number.
License Number
Additional license number (optional)
License must meet the following requirements:
Illinois professional license numbers begin with 2 - 3 letters and are 8 - 9 digits.
Example: MD974738L
*
Add
List of License numbers
Action
License Number
Expiry Date
Status
{{x.license}}
{{x.led}}
{{x.message}}
{{x.message}}
DEA
DEA must meet the following requirements:
DEA numbers begin with one letter followed by one letter or digit followed by 7 digits and are assigned by the US Drug Enforcement Administration.
Example: FS1234567
(Optional)
*
Add
I do not have a DEA Number
List of DEA numbers
Action
DEA Number
Status
{{x.dea}}
{{x.message}}
{{x.message}}
NPI
NPI must meet the following requirements:
National Provider Identifier is a 10-digit identification number issued by the Centers for Medicare and Medicaid Services.
Example: 1476614578
(Optional)
*
Add
List of NPI numbers
Action
NPI Number
Status
{{x.npi}}
{{x.message}}
{{x.message}}
NCPDP
License Expiry Date
*
Employer
Pharmacy
Information
My employer address is the same address I entered above.
Employer Name
Pharmacy Name
*
Employer Phone Number
Pharmacy Phone Number
Employer Address
Pharmacy Address
Employer State
Pharmacy State
Select a state
Employer City
Pharmacy City
Select a city
Other City Name
*
Employer ZIP Code
Pharmacy ZIP Code
Employer License Number
Pharmacy License Number
*
(if applicable)
Employer DEA
Pharmacy DEA
*
(if applicable)
Employer NPI
Pharmacy NPI
(if applicable)
*
I attest that the information I provided is my own and is true and accurate to the best of my knowledge.
*
I agree to notify the PDMP if I begin prescribing or dispensing controlled substances in Illinois in the future, so that I may gain access to query patients.
Type your name and today's date to electronically sign
*
Electronic Sign
*
Signature Date
*
Additional Information
Submit
Next Tab
The last name associated with the [DEA/NPI] does not match the last name on your Illinois professional license. Are you sure it is correct? Or The [DEA/NPI] you provided is not valid.
*
Yes
No
Next
{{msgCard3}}
Ok
×
Verify Phone number
Enter verification code to validate phone number *
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s)Resend
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