LEVEL ONE - REQUEST FORM
Preferred daytime telephone number:
Enroll in the Illinois Prescription Monitoring Program (PMP)
No, I am a resident. Please use my hospital/practice confirmation (please upload confirmation below).
Upload a copy of confirmation email or website confirmation upon enrollment in the IL PMP
Chose all the ways you would like to be like to be recognized as a Level One Safe Prescriber.
Certificate for display at the practice
Recognition on the IAFP list of Safe Prescriber on iafp.com
Comments or suggestions: Please let us know how we can better serve you and your practice in the area of education on controlled substances. Your input in important.
Thank you for completing the Safe Prescriber for Controlled Substances Program. Please allow 2-3 weeks for your request to be processed.
If you have any questions please contact the Illinois Academy of Family Physicians at 630.435.0257.
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