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YES, I'm ready to enroll in DHIN!

Please Complete the Enrollment Form Below

Thank you for expressing interest in the Delaware Health Information Network (DHIN). Please download and complete the form in Word format below so that we can have information about you and your practice in order to get you set up as a DHIN user. Once completed, please email the form to newuser@dhin.org.

If you're interested in learning more about enrolling in DHIN, fill out the form below! 

A DHIN implementation specialist will contact you within a few days to answer questions and help you complete the enrollment if interested.


Practice Group Name:
Date:
Address:
City:
County:
State:
Zip code:
Specialty:
Number of Clinicians:
(physicians, physician assistants and advance practice nurses)
Number of Staff:
Number of Practice Sites:

Location (towns or cities) of your other practice sites:
Please tell us about the technology you currently use (check all that apply):
Name of EMR Vendor:
Software Version:
Practice Management System:
Product Version:
Please specify:

Please identify a primary contact to serve as the DHIN Administrator:
Primary Contact:
Primary Title:
Primary Phone:
Primary Fax:
Primary Email:

How did you hear about DHIN:
Name of Event:
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