Georgia Department of Public Health Meaningful Use Registration
MU Registration
1 .
Organization Name:
2 .
Organization Street:
3 .
Organization City:
4 .
Organization County:
5 .
Organization State:
6 .
Organization Zip Code:
7 .
Organization Phone:
-
-
8 .
Organization Type:
Eligible Provider
Eligible Hospital
Critical Access Hospital
EHR Vendor
Other
Meaningful Use Point of Contact : (Group or Department or Person within Organization)
9 .
POC Name:
10 .
POC Title
11 .
POC Phone
-
-
12 .
POC Fax
-
-
13 .
POC Email Address
Alternate Meaningful Use Point of Contact : (Group or Department or Person within Organization)
14 .
A POC Name:
15 .
A POC Title
16 .
A POC Phone
-
-
17 .
A POC Fax
-
-
18 .
A POC Email Address:
19 .
Please indicate the public health meaningful use objectives for which you are pursuing attestation:
Syndromic Surveillance
Reportable Laboratory Results
Immunization Data
Cancer Data
Birth Defects Data
Alzheimer's Data
Electronic Case Reporting (eCR)
Please list the facilities for which you intend send data
20 .
Facility 1 Name:
21 .
Facility 1 County:
22 .
Facility 2 Name:
23 .
Facility 2 County:
24 .
Facility 3 Name:
25 .
Facility 3 County:
26 .
Facility 4 Name:
27 .
Facility 4 County:
28 .
Facility 5 Name:
29 .
Facility 5 County:
EHR Product and Vendor Information
30 .
EHR Product and Version Number:
31 .
EHR Vendor Name:
32 .
EHR Vendor Contact Name
33 .
EHR Vendor Telephone:
-
-
34 .
EHR Vendor Email:
35 .
Additional Facilities, Comments, Questions and/or Concerns
If you are a Cancer Reporter, please answer the following:
36 .
Primary Group NPI:
37 .
Physician Names/NPIs (or number of Physicians in Practice)
38 .
Number Cancer Cases Expected Monthly:
SendSS System Message:
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SendSS System Message:
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