RAPC Interface Request Form

Facility requesting interface.
How many providers at your facility?
Estimated monthly order volume.
Facility Contact Information

Point of contact for coordination of facility resources.
Name Name First Last
Phone Phone - ### - ### ####
Email
Interface information.
EMR to be interfaced?
Type of interface requested?

Type of interface requested? Orders Results
Facility you want to be interfaced with?

Facility you want to be interfaced with? Oregon Imaging Centers RAPC
Is your EMR hosted or supported by another entity?

Please provide a contact for your EMR service provider.
Name Name First Last
Phone Phone - ### - ### ####
Email
I.T. Contact information.

Please provide a contact I.T. related information. (Connectivity, VPN, Support)
Name Name First Last
Phone Phone - ### - ### ####
Email
Any additional information you would like to add not covered in the above form.