Request for Immunization or Electronic Laboratory Reporting (ELR)

Complete this form to submit a connection request to electronically submit immunizations to the Vermont Immunization Registry or reportable laboratory results to the Vermont Department of Health.


VITL operates the Vermont Health Information Exchange. Data submitters must sign a Data Use Agreement with VITL to establish a connection.

Enter the name of the reporting organization.

Select all the interfaces of interest. Select REPLACEMENT and the associated interfaces, if the request is to replace any existing interface connection already live with VITL.

Select all that apply.

Select or enter the name of your Electronic Health Record (EHR) system or source system.

Select or enter value
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Select or enter the names of any vendors who should be involved (e.g., EHR vendors, connection vendors, etc.). Feel free to add more detail in the Any Additional Notes field.

Select or enter value
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Please select the approximate size of the organization making the request.

Select
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If the EHR or source system are not in the selection lists, include it here.

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