Electronic Case Reporting

Page 1 of 1

Please complete the registration of intent form and we will get back to you shortly.

•

Name ✱

First	An answer is requiredFirst
Last	An answer is requiredLast

•

Organization ✱

Company Name

•

Title ✱

Title Name

•

Email ✱

•

Do you have an Electronic Health Record System? ✱

Yes

•

Please specify EHR system vendor. ✱

•

Please specify EHR product and version.

•

Technical Contact Email Distribution List

(highly recommended and preferred over individual contacts)

•

Technical Primary Point of Contact(s) Information

Matrix row labels are in this column	First Name	Last Name	Title	Email	Cell Phone Number	Office Number
Contact.1	An answer is requiredValue for matrix segment M1, row R1, column C1	An answer is requiredValue for matrix segment M1, row R1, column C2	An answer is requiredValue for matrix segment M1, row R1, column C3	An answer is requiredValue for matrix segment M1, row R1, column C4	An answer is requiredInvalid value	An answer is requiredValue for matrix segment M1, row R1, column C6
Contact.2	An answer is requiredValue for matrix segment M1, row R2, column C1	An answer is requiredValue for matrix segment M1, row R2, column C2	An answer is requiredValue for matrix segment M1, row R2, column C3	An answer is requiredValue for matrix segment M1, row R2, column C4	An answer is requiredInvalid value	An answer is requiredValue for matrix segment M1, row R2, column C6
Contact.3	An answer is requiredValue for matrix segment M1, row R3, column C1	An answer is requiredValue for matrix segment M1, row R3, column C2	An answer is requiredValue for matrix segment M1, row R3, column C3	An answer is requiredValue for matrix segment M1, row R3, column C4	An answer is requiredInvalid value	An answer is requiredValue for matrix segment M1, row R3, column C6

•

Is this organization currently or planning to attest for eCR under Promoting Interoperability (formerly Meaningful Use)?

Yes

•

Please provide your National Provider Identifier (NPI) number or Taxpayer Identification Number (TIN.)

•

What phase are you currently in regarding eCR onboarding status?

Stage 1e: On hold for another reason.

Stage 1f: On hold due to using a vendor that is not yet ready for general availability eCR onboarding.

Stage 2: Committed to start eCR, but not starting immediately (e.g., updating product, determining policy path).

Stage 3a: AIMS onboarding in progress.

Stage 3b: AIMS onboarding complete.

Stage 4: In-Production.

•

Do you have any other comments or questions?