Citywide Immunization Registry : NYC DOHMH

The New York City Department of Health and Mental Hygiene

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Citywide Immunization Registry (CIR)

Provider Registration Form

Enter all information requested below by typing on the computer keyboard in the available spaces.

Provider Information

First Name:
Middle Initial:
Last Name:
Name of Group Practice (if any, or if part of a network or hospital):
Street address:
Street address 2:
City:	Borough
State:
Zip code:

Contact Person

First Name:
Middle Initial:
Last Name:
Phone number:
Extension:
Fax number:
E-mail:

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

Staff 1
Title (Please check one): MD DO NP PA Other
First Name:
Last Name:
Provider NYS License Number:

Staff 2
Title (Please check one): MD DO NP PA Other
First Name:
Last Name:
Provider NYS License Number:

Staff 3
Title (Please check one): MD DO NP PA Other
First Name:
Last Name:
Provider NYS License Number:

Staff 4
Title (Please check one): MD DO NP PA Other
First Name:
Last Name:
Provider NYS License Number:

Staff 5
Title (Please check one): MD DO NP PA Other
First Name:
Last Name:
Provider NYS License Number:

Staff 6
Title (Please check one): MD DO NP PA Other
First Name:
Last Name:
Provider NYS License Number:

Staff 7
Title (Please check one): MD DO NP PA Other
First Name:
Last Name:
Provider NYS License Number:

Staff 8
Title (Please check one): MD DO NP PA Other
First Name:
Last Name:
Provider NYS License Number:

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Print and FAX the form to (347) 396-2400
--or--
Print and MAIL the form to:
Citywide Immunization Registry
NYC Dept. of Health and Mental Hygiene
42-09 28^th Street, 5^th Floor, CN 21
Long Island City, NY 11101-4132
--or--
CALL (347) 396-2400

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TOPIC CONTENTS

Citywide Immunization Registry (CIR)

Parents/Guardians & Individuals

What's New for Providers

Meaningful Use of Electronic Health Records (EHR) and CIR, and Medicare and Medicaid Incentive

How to Report

Online Registry Access and Reporting

Registry Services

Provider's Frequently Asked Questions

Parents, Guardians, & Individuals Frequently Asked Questions

Schools may sign up for Online Registry access