Direct Address Submission Form

Use this form to share the direct addresses for your providers.

Direct addresses typically look like an email address but contain the word "direct" and are used for secure communication/direct messaging from one EHR to another. For example, a typical direct address might have the format providername@direct.practiceehrname.com.

If you are unsure what the direct addresses are for providers using your EHR, please contact your EHR's technical support person.

1. Practice or Organization Name *This question is required.

2. Practice or Organization Street Address *This question is required.

3. City *This question is required.

4. State *This question is required.

5. Zip *This question is required.

6. Contact Name *This question is required.

7. Contact Phone Number *This question is required.

8. Contact Email *This question is required. This question requires a valid email address.

9. Please enter the direct addresses for each of the providers in your practice.

If you need to give us direct addresses for more than 10 providers, you can submit multiple forms. Alternatively, if you would prefer to send us a spreadsheet with the direct addresses for all your providers, please add a comment in the notes box below and we will follow up with you.

Space Cell	Provider NPI	Provider First Name	Provider Last Name	Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 1 *This question is required	Provider 1: Provider NPI	Provider 1: Provider First Name	Provider 1: Provider Last Name	Provider 1: Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 2	Provider 2: Provider NPI	Provider 2: Provider First Name	Provider 2: Provider Last Name	Provider 2: Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 3	Provider 3: Provider NPI	Provider 3: Provider First Name	Provider 3: Provider Last Name	Provider 3: Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 4	Provider 4: Provider NPI	Provider 4: Provider First Name	Provider 4: Provider Last Name	Provider 4: Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 5	Provider 5: Provider NPI	Provider 5: Provider First Name	Provider 5: Provider Last Name	Provider 5: Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 6	Provider 6: Provider NPI	Provider 6: Provider First Name	Provider 6: Provider Last Name	Provider 6: Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 7	Provider 7: Provider NPI	Provider 7: Provider First Name	Provider 7: Provider Last Name	Provider 7: Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 8	Provider 8: Provider NPI	Provider 8: Provider First Name	Provider 8: Provider Last Name	Provider 8: Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 9	Provider 9: Provider NPI	Provider 9: Provider First Name	Provider 9: Provider Last Name	Provider 9: Provider Direct Address (Example: providername@direct.practiceehrname.com)
Provider 10	Provider 10: Provider NPI	Provider 10: Provider First Name	Provider 10: Provider Last Name	Provider 10: Provider Direct Address (Example: providername@direct.practiceehrname.com)

Please add any notes, comments or questions below.

Direct Address Submission Form

Give Penn Medicine Your Direct Address