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CIR: Provider Registration Form

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.

     
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:
Title:
Role:
Phone number:
Extension:
Fax number:
E-mail:

 

1. Medical specialty (e.g., internal medicine, OB/GYN, etc.):

 

2. Do you currently provide immunizations to patients or are you planning to do so soon?
Yes
No

 


under 19 years 19 years or older all ages

 

4. Operating fund type:
Do you operate under
:
Private
Public (federal, state, or municipal)
Don't Know

 

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


For Providers and Hospitals that need to register their Meaningful Use intent:


7. Do you intend to submit immunization data to fulfill Meaningful Use (MU) requirements?
Yes
No

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:

Other

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]

Staff
Staff 1
Title (Please check one):
MD PA NP RPH Other
First Name:
Last Name:
Provider NYS License Number:
Staff 2
Title (Please check one):
MD PA NP RPH Other
First Name:
Last Name:
Provider NYS License Number:
Staff 3
Title (Please check one):
MD PA NP RPH Other
First Name:
Last Name:
Provider NYS License Number:
Staff 4
Title (Please check one):
MD PA NP RPH Other
First Name:
Last Name:
Provider NYS License Number:
Staff 5
Title (Please check one):
MD PA NP RPH Other
First Name:
Last Name:
Provider NYS License Number:
Staff 6
Title (Please check one):
MD PA NP RPH Other
First Name:
Last Name:
Provider NYS License Number:
Staff 7
Title (Please check one):
MD PA NP RPH Other
First Name:
Last Name:
Provider NYS License Number:
Staff 8
Title (Please check one):
MD PA NP RPH Other
First Name:
Last Name:
Provider NYS License Number:
     Listen to and enter into the text field the digits you hear 

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or
Print 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

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