Promoting Interoperability Registration

Promoting Interoperability Registration
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 or syndromic@mt.gov.
I have read and understand the purpose of this Promoting Interoperability registration*

I acknowledge
DPHHS may share your name with local health agencies and others in our follow-up and onboarding process*

I understand

Facility Information
Facility or HCO Name:*
If registering a single facility, is your facility part of a larger Healthcare Organization (HCO)?*

YesNo
Name of Healthcare Organization (HCO)*
If registering multiple facilities, please upload an Excel file with facility names and addresses here:

Cancelof
Facility Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you registering this facility due to an upcoming change in EHR and/or healthcare organization?*

YesNo

Contact Information
Promoting Interoperability Primary Contact*

First NameLast Name
Primary Title/Role*
Primary Email*
example@example.com
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Promoting Interoperability Technical Contact*

First NameLast Name
Technical Title/Role*
Technical Email*
example@example.com
Technical Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Provider Type
Facility/Provider Type*

Eligible Hospital (EH)Critical Access Hospital (CAH)Eligible Provider (EP)Eligible Provider with Emergency DepartmentCLIA Certified Laboratory
Group NPI:*
CLIA Number:*

Electronic Health Record Information
EHR Vendor:*
EHR Name:*
EHR Version:*
Is your EHR Certified? Certification can be checked here: https://chpl.healthit.gov/#/search*

YesNo

Public Health Reporting Objectives
I would like to register for the following:*

Cancer Case ReportingElectronic Case Reporting (eCR/eICR)Electronic Lab Reporting (ELR)ImmunizationsSyndromic Surveillance

Electronic Case Reporting (eCR/eICR)
Have you already started to implement eCR at your healthcare organization or facility?*

YesNo
Start date or anticipated start date for eCR implementation:*

MonthDayYear
Date

Immunization Registry
Is the Immunization Registry Technical contact the same as the contact provided at the beginning of this form?

YesNo
Technical Contact*

First NameLast Name
Technical Contact Email*
example@example.com
Technical Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Immunization Data Entry Supervisor*

First NameLast Name
Data Entry Supervisor Email*
example@example.com
Data Entry Supervisor Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Approximately how many immunizations do you provide annually?*

1-120121-500501-1,0001,001-5,0005,000+
Are you a Vaccines for Children (VFC) Provider?*

YesNo

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.*

I understand

Purpose
The purpose of this registration is to:*

Be placed in an interface development queue with MT DPHHSRegister for the federal Promoting Interoperability program

Comments
Please add any additional information relevant to the registration or onboarding process:
Should be Empty:

Montana Public Health Promoting Interoperability Registration