Electronic Case Reporting

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Please complete the registration of intent form and we will get back to you shortly.
Name ✱
Organization ✱
Company Name
Title ✱
Title Name
Email ✱
Do you have an Electronic Health Record System? ✱
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
First NameLast NameTitleEmailCell Phone NumberOffice Number
Is this organization currently or planning to attest for eCR under Promoting Interoperability (formerly Meaningful Use)?
Please provide your National Provider Identifier (NPI) number or Taxpayer Identification Number (TIN.)
What phase are you currently in regarding eCR onboarding status?
Do you have any other comments or questions?