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 Registration 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.

Provider Information
Physician's First Name Physician's Middle Initial Physician's Last Name Name of Group Practice (if any, or if part of a network or hospital) Address Address Line 2 City Borough State ZIP Contact Person's First Name Contact Person's Middle Initial Contact Person's Last Name Phone Extension FAX Email Population Served (check all that apply): Adults: Children under 19 years old: Medical specialty (e.g., internal medicine, OB/GYN, etc.): Estimated Number of Weekly Immunization Visits at Your Practice: Check here to receive further information about electronic reporting: Check here for free training in online access and reporting:
Staff
Please list below all MD/DOs, PAs and NPs providing immunization services.
	Last Name	First Name	MD/DO, PA, NP	Provider NYS License Number
1
2
3
4
5
6
7
8
CLICK the button below to send your registration 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