Health Plan / PBM subscription - Weno Exchange

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Health Plan / PBM

1Company Information

2Software Information

3Contact Information

Company Information

Legal Company Name *

DBA (if exists)

Company Address

U.S.
International

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address - International *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Main company phone *

Is your company's billing address different from the mailing address?

Same
Different

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Billing Address - International *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Attention to:

Billing email address:

Billing Phone (if different from Co. main)

Software Name *

Description

Integration Format *

JSON
XML
Not Sure

Will your technology receive eRx messages on: *

Only one listening endpoint
More than one listening endpoint
Not sure

Admin Contact Name *

First

Last

.

Admin Mobile Number *

Admin Email *

Lead Developer

Same as Main Contact

Developer Name

First

Last

Developer Email

Developer Mobile Number

How did you hear about WENO?

Friend or colleague
Google
Other web search
Social media
News article
Other

-- Click here to read and download our Privacy Policy and Agreement --

Are you authorized to accept the terms & conditions of the Privacy Policy & Agreement on behalf of the person or entity named in this form ? *

Yes
No

Please enter the authorized person*

Authorized Person's *

First

Last

.

I have read and accepted the latest Privacy Policy & WENO Exchange LLC Agreement as of date: *

I have read and accepted the latest Privacy Policy & WENO Exchange LLC Agreement as of date:

Sorry, if you are not an authorized person to register for WENO Exchange LLC Agreement and accept WENO Exchange LLC Agreement you can't continue this process.

Health Plan / PBM subscription *

Price: $1,200.00

( initial payment is for 1 health or prescription plan - WENO will invoice trading partner for additional required plans. )

Stripe Credit Card *

Card

Name on Card

Phone

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WENO Online
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Cert. Site
Live Site

Support

admin@wenoexchange.com
877-890-3726

© WENO EXCHANGE LLC

2024

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2021 Prescriber eRx Application EPCS Compliance Evidence

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