Montana Public Health Promoting Interoperability Registration

This registration is intended to register your facility’s interest in creating an interface or interfaces with the Montana Department of Public Health and Human Services (DPHHS) . Completing this registration indicates your facility is ready to submit data electronically to one or many of the following registries, as indicated by this registration:


Cancer Case Reporting

Electronic Case Reporting

Electronic Lab Reporting

imMTrax (immunization information system)

Syndromic Surveillance


Please note that this registration is separate from your Medicare/Medicaid Promoting Interoperability registration/attestation requirements.


If you have any questions about this registration, please contact MIDIS@mt.gov

I have read and understand the purpose of this Promoting Interoperability registration*
DPHHS may share your name with local health agencies and others in our follow-up and onboarding process*

Facility Information

Facility Address*
Is your facility part of a larger Healthcare Organization (HCO)?*

Contact Information

Promoting Interoperability Primary Contact*
Promoting Interoperability Technical Contact *

Provider Type

Facility/Provider Type*

Group NPI

Electronic Health Record Information

Is your EHR Certified? Check certification here: https://chpl.healthit.gov/#/search*

Public Health Reporting Objectives

Eligible Hospital*
Critical Access Hospital*
Eligible Provider*
Eligible Provider with Emergency Department*
CLIA Certified Laboratory*
Eligible Hospital and Critical Access Hospital*
Eligible Hospital and Eligible Provider*
Eligible Hospital and Eligible Provider with Emergency Department*
Eligible Hospital and CLIA Certified Laboratory*
Critical Access Hospital and Eligible Provider*
Critical Access Hospital and Eligible Provider with ED*
Critical Access Hospital and CLIA Certified Laboratory *
Eligible Provider and Eligible Provider with Emergency Department*
Eligible Provider and CLIA Certified Laboratory*
Eligible Provider with Emergency Department and CLIA Certified Laboratory*
Eligible Hospital, Critical Access Hospital, and Eligible Provider*
Eligible Hospital, Critical Access Hospital, and Eligible Provider with Emergency Department*
Eligible Hospital, Critical Access Hospital, and CLIA Certified Laboratory*
Eligible Hospital, Eligible Provider, and Eligible Provider with Emergency Department*
Eligible Hospital, Eligible Provider, and CLIA Certified Laboratory*
Eligible Hospital, Eligible Provider with Emergency Department, and CLIA Certified Laboratory*
Critical Access Hospital, Eligible Provider and Eligible Provider with Emergency Department*
Critical Access Hospital, Eligible Provider and CLIA Certified Laboratory*
Critical Access Hospital, Eligible Provider with Emergency Department and CLIA Certified Laboratory*
Eligible Provider, Eligible Provider with Emergency Department and CLIA Certified Laboratory*
Eligible Hospital, Critical Access Hospital, Eligible Provider and Eligible Provider with Emergency Department*
Eligible Hospital, Critical Access Hospital, Eligible Provider with Emergency Department and CLIA Certified Laboratory*
Eligible Hospital, Eligible Provider, Eligible Provider with Emergency Department and CLIA Certified Laboratory*
Eligible Hospital, Critical Access Hospital, Eligible Provider and CLIA Certified Laboratory*
Critical Access Hospital, Eligible Provider, Eligible Provider with Emergency Department and CLIA Certified Laboratory*
Eligible Hospital, Critical Access Hospital, Eligible Provider, Eligible Provider with Emergency Department and CLIA Certified Laboratory*

Electronic Case Reporting

Does your facility utilize a larger EHR/EMR/Software that has already been onboarded for ECR?*

Electronic Lab Reporting

Has your facility established a connection before?*

Immunization Registry

Technical Contact*
Immunization Data Entry Supervisor*
Approximately how many immunizations do you provide annually?*
Are you a Vaccines For Children (VFC) Provider?*

Cancer Registry

You have indicated that you would like to submit electronic data to our Cancer Registry. Please be advised that you will need to ensure that your certified EHR has a Cancer Reporting Module ready for you to submit data. If your EHR does not have this reporting module, you will not be able to submit data to the MT Cancer Registry. *

Purpose

The purpose of this registration is to:*

Comments

Please add any other additional information relevant to the registration process:

Powered by Formstack Create your own form ›
Cancel
Confirm