Contact Inquiry Form

Complete the form below to contact the Outreach Coordinator, Robin Hepfinger. She will assist you with the Medicaid EHR Incentive Program and technical support services.

Provider First Name:

Provider Last Name:

Job Title:

Individual NPI #: (If you do not know this number please enter 9 ten times.)

Street Address:

City:

Zip Code:

State:

Phone Number:

Email Address:

If you are completing this form for a provider, please enter your first and last name below.

Contact First Name:

Contact Last Name:

Preferred Method Of Communication:

Message: