Enter all information requested below by typing on the computer keyboard in the available spaces.
If you are already registered with CIR and intend to submit immunization data to fulfill Meaningful Use (MU), please enter your practice information and answer the questions.
4. Operating fund type: Do you operate under:
Public (federal, state, or municipal)
5. Would you like to participate in the federal Vaccines for Children (VFC) program? Yes (you will be contacted directly by the program) No
6. How do you plan to report immunizations to the CIR? (check all that apply)
HL7 Web service Online Registry Website Electronic Batch File Transfer (Non-HL7) N/A
7. Do you intend to submit immunization data to fulfill Meaningful Use (MU) requirements?
Please select the certified electronic health record (EHR) system you are using. If you do not see your EHR in this list, please check 'Other' below and enter the name of your EHR system:
Advanced Data Systems
Allscripts Sunrise Clinical Manager
American Medical Software
Care 360 (Quest Diagnostics)
Enable Healthcare Inc
Office Practicum (Connexin)
STI Computer Services
Please indicate which stage of MU you are currently working towards Stage 1 Stage 2
Please enter the start date of your 90-day MU reporting period [if unknown, please enter approximate date]
orPrint and FAX the form to 347-396-2559 --or--Print and MAIL the form to: Citywide Immunization Registry NYC Dept. of Health and Mental Hygiene 42-09 28th Street, 5th Floor, CN 21 Long Island City, NY 11101-4132 --or--CALL (347) 396-2400