PDMP Form

PDMP Online Request Form

Sevocity’s medication portal allows for PDMP checking to ensure that providers are able to prevent prescription drug abuse and adhere to any state requirements for PDMP checking.

There is one-time per practice enrollment fee of $595 to establish the interface with the state as well as a $10 monthly per provider fee (each provider with EPCS will be billed $10 monthly).

Note: EPCS is required to enroll in PDMP. EPCS requires a one-time start-up fee of $125 and providers requesting EPCS must have a current DEA license.

Please fill out the information below to submit a request for your clinic.

Clinic Information

Clinic Name:*

Account Billing ID:*

Clinic Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Clinic Phone:*

Date:*

State(s) Being Requested:*

*The PDMP registration Clinic information must match what shows on the Sevocity contract to avoid delays. If the Clinic information above does not match our records, you will be contacted to verify information

Provider Name(s) Requesting PDMP (currently with EPCS):*

*Providers must currently be active with EPCS in order for a PDMP request to be processed. Otherwise, you must add EPCS services for the Provider. Please include the name of the provider below you wish to add EPCS services that is currently NOT enrolled.

Provider Name(s) Requesting PDMP (currently w/o EPCS):*

Billing Point of Contact

Name:*

Phone:*

Email:*

PDMP Request Point of Contact

Would you like to enter another point of contact for PDMP?*

Yes No, Same As Above

Name:

Phone:

The PDMP process may take several weeks as each state’s processing timeframe varies.

Click here to view the PDMP FAQs.

Contact Sevocity Support at 877-777-2298 or pdmp@sevocity.com for any questions.