This registration form is designed to be used to register for cancer and immunization data reporting only. You will receive an email confirmation after completing the registration process. To register for electronic lab reporting and syndromic surveillance, click on the respective link below.


** indicates required field.

Select the public health data you are registering your intent to submit under Stage 2 Meaningful Use (MU2): **
(You may register for both cancer and immunization at the same time.)

Electronic Lab Reporting Syndromic Surveillance

Select your organization type: **




Practice/Reporting Entity Information: **

Practice/Reporting Entity Name:
Practice/Reporting Entity Street Address:
Practice/Reporting Entity City:
Practice/Reporting Entity State:
Practice/Reporting Entity Zip Code:
Practice/Reporting Entity County:
Practice/Reporting Entity Phone:
Practice/Reporting Entity NPI:


Electronic Health Record (EHR) Vendor Information: **

EHR Vendor Name:
EHR Product Name:
EHR Product Version:


Electronic Health Record (EHR) Vendor Point of Contact (POC): **



Alternate Electronic Health Record (EHR) Vendor Point of Contact (POC):

POC First Name: Alternate POC First Name:
POC Last Name: Alternate POC Last Name:
POC Title: Alternate POC Title:
POC Phone: Alternate POC Phone:
POC Email: Alternate POC Email:
Reenter Email address: Reenter Email address:


Practice/Reporting Entity MU Point of Contact (POC): **



Alternate Practice/Reporting Entity MU Point of Contact (POC):

POC First Name: Alternate POC First Name:
POC Last Name: Alternate POC Last Name:
POC Title: Alternate POC Title:
POC Phone: Alternate POC Phone:
POC Email: Alternate POC Email:
Reenter Email address: Reenter Email address:


Technical Point of Contact (POC): **



Alternate Technical Point of Contact (POC):

Check if Technical POC is the same as Vendor POC
Check if Technical POC is the same as Practice/Entity MU POC

POC First Name: Alternate POC First Name:
POC Last Name: Alternate POC Last Name:
POC Title: Alternate POC Title:
POC Phone: Alternate POC Phone:
POC Email: Alternate POC Email:
Reenter Email address: Reenter Email address:


Click the Continue button to proceed with the registration or click Clear Form to start over.




Please confirm your entries and enter the requested information below in order to complete the registration.

Registering for:



Organization type:



Practice/Reporting Entity Information:

Practice/Reporting Entity Name:
Practice/Reporting Entity Street:
Practice/Reporting Entity City:
Practice/Reporting Entity State:
Practice/Reporting Entity Zip Code:
Practice/Reporting Entity County:
Practice/Reporting Entity Phone:
Practice/Reporting Entity NPI:


Electronic Health Record (EHR) Vendor Information:

EHR Vendor Name:
EHR Product Name:
EHR Product Version:


Electronic Health Record (EHR) Vendor Point of Contact (POC):



Alternate Electronic Health Record (EHR) Vendor Point of Contact (POC):

POC First Name: Alternate POC First Name:
POC Last Name: Alternate POC Last Name:
POC Title: Alternate POC Title:
POC Phone: Alternate POC Phone:
POC Email: Alternate POC Email:


Practice/Reporting Entity MU Point of Contact (POC):



Alternate Practice/Reporting Entity MU Point of Contact (POC):

POC First Name: Alternate POC First Name:
POC Last Name: Alternate POC Last Name:
POC Title: Alternate POC Title:
POC Phone: Alternate POC Phone:
POC Email: Alternate POC Email:


Technical Point of Contact (POC):



Alternate Technical Point of Contact (POC):

POC First Name: Alternate POC First Name:
POC Last Name: Alternate POC Last Name:
POC Title: Alternate POC Title:
POC Phone: Alternate POC Phone:
POC Email: Alternate POC Email:


If you need to make changes to the information you entered click the Edit Entries button. If you have no further changes enter your name below and click the Submit button.

Name of person filling out registration form:

First Name:

Last Name: