HL7 ELR Registration

For Facility Name and Address fields, use a main location for your organization. Refer to the Communicable Disease Manual for the list of reportable conditions for NC DPH https://epi.dph.ncdhhs.gov/cd/lhds/manuals/cd/reportable_diseases.html

What type of facility are you registering?*

Select

Lab Type if "Other"

Enter all CLIA numbers for facilities you are reporting for:*

Please separate by semi-colon

Facility Name*

Facility Address 1*

Facility Address 2

Facility City*

Facility State*

Facility Zip Code*

Contact Information

Please enter a main contact for each, more can be added later

Main Lab Contact Name*

Main Lab Contact Position Title

Main Lab Contact Email Address*

Main Lab Contact Phone Number*

Main IT Contact Name

Main IT Contact Organization

If different than the facility being registered

Main IT Position Title

Main IT Email Address

Main IT Phone Number

Main LIS Vendor Contact Name

Main LIS Vendor Contact Organization*

Main LIS Vendor Contact Position Title

Main LIS Vendor Contact Email Address

Main LIS Vendor Contact Phone Number

Current Volume of Tests Performed

*Include the number of tests performed monthly for NC residents performed in your facility(ies). DO NOT include tests sent to a third party lab, i.e. Quest, Labcorp, etc.

Estimated MONTHLY TOTAL number of all test results reportable to NC public health currently performed for NC residents*

Select

What results are most frequently reported to Public Health?*

i.e. chlamydia trachomatis, Positive for Hep B core antigen

Are there any anticipated changes in testing volume?*

Select

Describe any anticipated changes, i.e. any increases, decreases, or change in testing type:

Which reference lab(s) does your facility use?

Current HL7 Capabilities

Are you currently sending HL7 ELR messages to other states?*

Select

List any states or other jurisdictions that are currently being reported to

*Please include states that are in Test but indicate that they are not in Production yet

Does your facility utilize a PHINMS connection?*

Select or enter value

Does your facility currently have a connection through the North Carolina Health Information Exchange Authority (HIEA)?*

Select

Are you currently faxing reportable test results to NC DHHS or county health department(s)?*

Include only tests resulted in your facility(ies)

Select or enter value

Which Local Health Department(s) are being faxed to?

Include where the majority of faxes are being sent, not every county sent to

What Laboratory Information System(s) (LIS) is/are your facility(ies) currently using?*

Please separate multiple values by a semi-colon

Are there any anticipated changes in LIS utilized?

Select

Estimated time frame for this transition:

Select

New LIS Vendor/Product Name:

File Upload

Please submit a list of all facilities, with CLIA number, that you will be reporting on.

Drag and drop files here or

Send me a copy of my responses

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