CIR: Provider Registration Form

Information and Resources
For Your Health

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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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or
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