Client Tools

Enrollments and Deactivation Forms

Please select the Enrollment/Deactivation Form from the drop-down.

Select

Provider/Practice Services Deactivation
Provider/Practice Services Deactivation Form
Administrator Authorization
Administrator Authorization Form
Faxing
STI Electronic Faxing Enrollment
Add/Disable Cloud Users
Cloud Clients – Add and/or Disable a User
Health Portal Services Enrollment (e-Prescribe, Labs, etc.)
Provider/Practice Deactivation – Please use this form if you are a practice or need to deactivate a provider(s) from multiple services at once

Health Portal Enrollment Form (Provider) – Register a provider for multiple services at once. Includes enrolling for E-Prescribing, Direct Messaging, EPCS , ePA Enrollment, PatientPortal and/or Provider Complete.

Health Portal Deactivation Form (Provider)

Lab/Interfaces Enrollment

Practice Level Direct Address – Request Form

Prescription Drug Monitoring Program (PDMP) Enrollment

Prescription Drug Monitoring Program (PDMP) Deactivation
Meaningful Use
Meaningful Use Training and/or Attestation Assistance
MIPS Assistance Enrollments

MIPS Assistance Program Enrollment

MIPS Attestation Assistance
Mobile App Beta Release
Mobile App Beta Enrollment
Order Supplies / Add or Replace Workstation Request
Order Supplies Form

Add/Replace Billing Workstation – Request Form
Patient Portal (Enrollment/Deactivation)
PatientPortal Enrollment and/or Deactivation
Provider Complete/ Electronic Patient Statements / Carisk

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 Here
Registries (Enrollment/Deactivation)
Quality Payment Program

ENROLLMENT: STI Quality Reporting Registry

DEACTIVATION: STI Quality Reporting Registry

Premier (Genesis) Qualified Clinical Data Registry

Premier (Genesis) Qualified Clinical Data Registry Enrollment

Premier (Genesis) Qualified Clinical Data Registry Deactivation

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
Training Assistance

General Training Request

Template Editing Request

Primary Care First Assistance Request

PCMH Assistance Request