HL7 ELR Provider Registration Form

HL7 ELR Provider Registration Form

Eligible Hospitals and Critical Access Hospitals (CAHs) must submit Electronic Laboratory Reports (ELR) as a core item in order to meet Promoting Interoperability Program requirements. This form should be completed and submitted to indicate intent to initiate ELR with the Texas Department of State Health Services (DSHS). If you have any question, please email IDI@DSHS.TEXAS.GOV

1. Please Indicate your facility's status:*

Select

2. Registering your intent with DSHS to initiate Health Level 7 (HL7) ELR?*

Select

3. CLIA Number of Reporting Facility (##D#######)*

4. Legal Business Name of the facility reporting ELR*

5. Address of Reporting Facility*

(e.g., 123 Sesame Street; if suite, please include)

6. City of Reporting Facility*

7. State (e.g., TX) of Reporting Facility*

8. ZIP Code (e.g., #####) of Reporting Facility*

9. Primary Contact Name*

10. Primary Contact Phone number (e.g., ###-###-####)*

11. Primary Contact Extension

12. Primary Contact E-mail Address*

13. Secondary Contact Name

14. Secondary Contact Phone number (e.g., ###-###-####)

15. Secondary Contact Extension

16. Secondary Contact Email Address

17. Number of reporting Facilities*

(If reporting greater than one (1) facility, then please complete the bulk registration template and attach the completed worksheet in the following "File Upload" field for us to verify, validate, and update our records).

File Upload

Drag and drop files here or

18. Name of EHR Software used to report data

19. Product Name

20. EHR LIS Software Version

21. Healthcare Organization (HCO ) or Health System (HS) name

A health system, also sometimes referred to as health care system or healthcare organization, is the organization of people, institutions, hospitals, and resources that deliver health care services to meet the health needs of target populations.

22. Can your system create HL7 ORU version 2.5.1 messages?*

Select

23. Most Frequently Reported Tests (e.g., PCR, IgM, etc.,)*

Tests that are mostly performed at the reporting facility (responses by a comma)

24. Facility include results sent to a reference lab?*

It is recommended that your facility include test results sent to a reference laboratory for testing. Facility disclose those results processing in the ELR interface.

Select or enter value

25. How many LIMS or Lab Information Management Systems Do you have*

26. Does your facility plan to seek attestation to confirm your compliance with CMS Promoting Interoperability Program requirements?*

https://www.cdc.gov/datainteroperability/index.html

Select

27. Date Registered*

Send me a copy of my responses

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