Enrollments and Deactivations Please select the Enrollment/Deactivation Form from the drop-down. Select:Select from the drop-down menuAdd/Replace Workstation RequestAdministrator AuthorizationChange Healthcare/Electronic Patient Statements/CariskChartMaker Mobile AppCloud Users Add/DisableDragon Medical One - DictationeFaxing (Updox)Lab/InterfacesMIPS Assistance ProgramOrder SuppliesPatient Pay OnlinePatient PortalPatient Reminder ModuleProvider/Practice ServicesRegistries (Healthmonix, Immunization, Premier)Telemedicine EnrollmentTraining Request Provider/Practice Services Activation - Register a provider for multiple services at once. Includes enrolling for E-Prescribing, Direct Messaging, EPCS , ePA Enrollment, PatientPortal and/or Provider Complete. Provider/Practice Services Deactivation Form Practice Level Direct Messaging Address – Request Form Prescription Drug Monitoring Program (PDMP) Enrollment Prescription Drug Monitoring Program (PDMP) Deactivation PatientPortal Enrollment and/or DeactivationCloud Clients – Add and/or Disable a User STI Electronic Faxing Enrollment STI Electronic Faxing Deactivation For FIRST-TIME enrollments, adding a NEW PROVIDER to an existing enrollment, DEACTIVATION of an existing provider and ELECTRONIC PATIENT STATEMENTS: Change Healthcare Provider Complete Enrollment & Deactivation Carisk – Enrollment Form >>> Click HerePatient Reminder Module EnrollmentPatient Pay Online EnrollmentChartMaker Mobile App Enrollment MIPS Assistance Program Enrollment (2022) MIPS Attestation Assistance Quality Payment Program Healthmonix - STI Quality Reporting Registry Enrollment (2022) Healthmonix - STI Quality Reporting Registry Deactivation (2022) Premier Qualified Clinical Data Registry Premier Qualified Clinical Data Registry Enrollment (2022) Premier Qualified Clinical Data Registry Deactivation (2022) Premier Attestation Letter Request Immunization Registry Delaware DELVAX Immunization Registry 2.5.1 Enrollment KIDS Plus (Philadelphia) KIDS Enrollment Instructions KIDS Clinic-Enrollment Form New Jersey NJIIS Immunization Registry 2.5.1 NJIIS Consent to Share Form New York Checklist to Go Live with NYSIIS NY Immunization Registries 2014 Pennsylvania (Outside of Philadelphia) PASIIS Enrollment Instructions Provider Interest Form Final Confidentiality Policy Final Facility Agreement – HL7 PA-SIIS Implementation Form – HL7 Revised EMR-HL7 Profile Form Facility Matrix Virginia VIIS Immunization Registry 2.5.1 Lab/Interfaces Enrollment General Training Request Template Editing Request Primary Care First Assistance Request PCMH Assistance Request Administrator Authorization FormOrder Supplies FormAdd/Replace Billing Workstation Request FormSTI Telemedicine – Enrollment FormDragon Medical One - Enrollment Form
