Promoting Interoperability Attestation Letters

Promoting Interoperability Attestation Letter Request Form
We launched a dashboard for Syndromic Surveillance and Electronic Laboratory Reporting (ELR) Promoting Interoperability status. Letters will not be sent for syndromic surveillance or ELR, so please take a screenshot of the dashboard for your records. Please contact syndromic@mt.gov with any questions
I understand I will not receive a letter for Syndromic Surveillance or ELR and will need to check the dashboard linked above to find my Promoting Interoperability status.*

I understand
Promoting Interoperability Contact Name:

First NameLast Name
Promoting Interoperability Contact Email:
example@example.com
Are there additional contacts or shared mailboxes who should also receive the attestation letter(s)? Please list contact name, email, and facility affiliation.
For which program(s) would you like an attestation letter?

Electronic Case Reporting (eCR)Electronic Laboratory Reporting (ELR)Immunization Registry (imMTrax)Syndromic Surveillance
For which facilities/providers would you like an attestation letter? Please list each facility on a separate line.
Should be Empty:

Promoting Interoperability Attestation Letter Request Form