CalREDIE - Electronic Case Reporting Enrollment

Contact Information
First Name* MI Last Name*
*Phone Email Address*
x
Title  

*Is the organization you're registering part of a larger organization.
  If Yes, please provide the Parent Organization?		 Yes No
*Enter Parent Organization Name:

Add Medical Facilities
Enter Organization NPI:    
Organization Name*
Address 1* Address 2
City* State* Zip Code* County*

 CalREDIE Electronic Case Reporting (eCR) Supplemental Data
Organization DBA [if this organization does business as or is referred to by another name, please enter it below.]
*Select Organization Type *Select the Local Health Jurisdiction where this facility is located Select Submission Type for this facility
Health Information Exchange
*Will this organization being submitting via the eCR NOW FHIR Application? Yes  No  Unknown
 Electronic Health Record (EHR) Information
*EHR Vendor (Company) EHR Product/Version
 *Electronic Case Reporting (eCR) Compatibility
Is your EHR capable of generating an electronic initial case report (eICR) in accordance with the national standard as described in the HL7 CDA R2 Implementation Guide Public Health Report - the Electronic Initial Case Report (eICR)? Yes
No
Unknown
 *Current CMR Submission Method
 Select your CURRENT method of submission of organization's reportable disease results data. (SELECT ALL THAT APPLY)
 CalREDIE Provider Portal
 Confidential Morbitity Report form faxed/mailed to Local Health Department
 Other
               *Please Specify:
 *Meaningful Use
Is this organization currently or planning to attest for eCR under Promoting Interoperability (formerly Meaningful Use)? Yes No