N.C. Diabetes Registry Registration Form

Submitted by aljohnson on Fri, 07/02/2021 - 16:02

Complete and submit this form to demonstrate your intent to submit data to the NC HealthConnex Diabetes Registry operated by the N.C. Health Information Exchange Authority in collaboration with the N.C. Department of Health and Human Services' Division of Public Health.

This registry will help your organization and providers meet Meaningful Use objectives from the U.S. Centers of Medicare & Medicaid Services. Please note: Registration in the Diabetes Registry is voluntary. If you do not participate in Meaningful Use or other incentive programs, you do not need to register.

After submitting this form, you will receive an email from NC HIEA. Please forward this email to your participating providers. To support your Meaningful Use attestation, your organization needs to send out these Diabetes Registry active engagement emails to each health care provider participating in the Meaningful Use disease registry objective.

Indicates required field

Contact

This person will receive all communications about registration with the N.C. Diabetes Registry.

First Name

Last Name

Phone

Organization

Title

Participant Authorization

The organization named above authorizes and intends to submit data to the NC HealthConnex Diabetes Registry operated by the N.C. Health Information Exchange Authority in collaboration with the N.C. Department of Health and Human Services Division of Public Health.

I attest that have read and acknowledged the above statement.

Signed by

(Typing your name serves as your signature.)

Email Address

Have Questions?

Please let the N.C. Health Information Exchange Authority know about any questions, comments or feedback you have on registration for the N.C. Diabetes Registry.

This question is for testing whether or not you are a human