ClinicalVault Participation Agreement Request Form

    NPI (required)

    First Name (required)

    Last Name (required)

    Your Email (required)

    Phone Number



    EHR Product (required)


    30 Thank you for your interest in becoming part of our ClinicalVault Health Information Exchange platform. Please provide us with the following information to receive your electronic ClinicalVault Participation Agreement Form via email.


    Once you receive your Agreement Form, please complete the information required on page 1, initialize all pages, sign and return via Docusign, via email at or via fax to (787)259-4948.


    For any question regarding your Agreement, contact de ClinicalVault Department.

    We are more than happy to assist you!