Enrollments and Deactivations Please select the Enrollment/Deactivation Form from the drop-down. Select:Select from the drop-down menuAdd/Replace Workstation RequestAdministrator AuthorizationChartMaker Mobile AppCloud Users Add/DisableDragon Medical One - DictationeFaxing (Updox)Insurance Electronic BillingLab/InterfacesMIPS Assistance ProgramOrder SuppliesPatient BillingPatient Pay OnlinePatient PortalPatient Reminder ModuleProvider/Practice ServicesRegistries (Healthmonix, Immunization, Premier)Training 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 Patient eStatements and Bill Reminders EnrollmentEnroll a Practice or Provider for Change Healthcare Provider Complete Deactivate a Provider from Change Healthcare Provider Complete Enroll for Carisk No Fault and Worker's Compensation ClaimsPatient Reminder Module EnrollmentPatient Pay Online EnrollmentChartMaker Mobile App Enrollment MIPS Assistance Program Enrollment (2022) MIPS Assistance Program Enrollment (2023) MIPS Attestation Assistance Quality Payment Program Healthmonix - STI Quality Reporting Registry Enrollment (2022) Healthmonix - STI Quality Reporting Registry Deactivation (2022) Healthmonix - STI Quality Reporting Registry Enrollment (2023) Healthmonix - STI Quality Reporting Registry Deactivation (2023) Premier Qualified Clinical Data Registry Premier Qualified Clinical Data Registry Enrollment (2022) Premier Qualified Clinical Data Registry Deactivation (2022) Premier Attestation Letter Request Premier Qualified Clinical Data Registry Enrollment (2023) Premier Qualified Clinical Data Registry Deactivation (2023) 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 FormDragon Medical One - Enrollment Form
