Provider Contact Update Form

The New York City Department of Health and Mental Hygiene

Click here to look up records and report immunizations online with The Registry!

Provider Contact Update Form

Directions:
Enter all information requested below by typing on the computer keyboard in the available spaces. Use the Tab button to move from box to box or use your mouse to point and click. Use your Space Bar to make checks within the boxes. After all of the information is entered, use the Send button at the bottom of the page to submit the form.

Facility Information
Facility Name Facility Code Phone Extension FAX	Address Address Line 2 City State ZIP
1. Medical Contact
Name
	First Name Last Name Suffix (MD, etc) Title Email
Address
Same as Facility Address Use Other (specify to the right)	Address Address Line 2 City State ZIP
Phone/FAX
Same As Facility Phone plus Ext. Use Other (specify to the right) Same As Facility FAX Use Other (specify to the right)	Phone Extension FAX

2. Administrative Contact
Name
	First Name Last Name Suffix (MD, etc) Title Email
Address
Same as Facility Address Use Other (specify to the right)	Address Address Line 2 City State ZIP
Phone/FAX
Same As Facility Phone plus Ext. Use Other (specify to the right) Same As Facility FAX Use Other (specify to the right)	Phone Extension FAX

3. MIS Contact
Name
	First Name Last Name Suffix (MD, etc) Title Email
Address
Same as Facility Address Use Other (specify to the right)	Address Address Line 2 City State ZIP
Phone/FAX
Same As Facility Phone plus Ext. Use Other (specify to the right) Same As Facility FAX Use Other (specify to the right)	Phone Extension FAX

4. Registry Contact
Name
Same as Medical Contact Same as Administrative Contact Use Other (specify to the right)	First Name Last Name Suffix (MD, etc) Title Email
Address
Same as Facility Address Use Other (specify to the right)	Address Address Line 2 City State ZIP
Phone/FAX
Same As Facility Phone plus Ext. Use Other (specify to the right) Same As Facility FAX Use Other (specify to the right)	Phone Extension FAX

5. Director of Pediatrics (if applicable)
Name
	First Name Last Name Suffix (MD, etc) Title Email
Address
Same as Facility Address Use Other (specify to the right)	Address Address Line 2 City State ZIP
Phone/FAX
Same As Facility Phone plus Ext. Use Other (specify to the right) Same As Facility FAX Use Other (specify to the right)	Phone Extension FAX

6. Nursing Director Neonatology (if applicable)
Name
	First Name Last Name Suffix (MD, etc) Title Email
Address
Same as Facility Address Use Other (specify to the right)	Address Address Line 2 City State ZIP
Phone/FAX
Same As Facility Phone plus Ext. Use Other (specify to the right) Same As Facility FAX Use Other (specify to the right)	Phone Extension FAX

7. Director of Ambulatory/Outpatient Pediatrics (if applicable)
Name
	First Name Last Name Suffix (MD, etc) Title Email
Address
Same as Facility Address Use Other (specify to the right)	Address Address Line 2 City State ZIP
Phone/FAX
Same As Facility Phone plus Ext. Use Other (specify to the right) Same As Facility FAX Use Other (specify to the right)	Phone Extension FAX

8. Chief Executive Officer (if applicable)
Name
	First Name Last Name Suffix (MD, etc) Title Email
Address
Same as Facility Address Use Other (specify to the right)	Address Address Line 2 City State ZIP
Phone/FAX
Same As Facility Phone plus Ext. Use Other (specify to the right) Same As Facility FAX Use Other (specify to the right)	Phone Extension FAX
CLICK the button below to send your form via the internet. --or-- Print and FAX the form to (212) 676-2314 --or-- Print and MAIL the form to: Citywide Immunization Registry 125 Worth St. CN #64R New York, NY 10013-4089 --or-- CALL (212) 676-2323

Click here if you wish to obtain a voter registration form. Government services are not conditioned on being registered to vote. A voter registration form can also be obtained at http://nyc.gov/html/misc/html/register.html, or by calling (212) 868-3692.

September 2002