OID Request Form

OID Request Form

Use this form to request one of the following:

Organization OID for Electronic Lab Reporting (ELR) or other electronic data exchange projects that require an OID to create globally unique identifiers for sending or receiving facility, patient ID, order number, specimen ID etc, when the facility is the assigner.

System OID for the same purpose for sending or receiving applications, patient ID, order number, specimen ID etc, when the data system is the assigner (more common) - in this case you will also need to provide information about the organization that operates / maintains the system.

For non-traditional lab reporters ONLY: Fake CLIA

Indicate if you need a Fake CLIA number so that your messages can be received by Public Health Agencies.

Fields with * are REQUIRED!

Type of OID Request*

Select

Facility Name*

Enter the name of the facility that needs an OID.

Fake CLIA Request

Check this box, if you need a FAKE CLIA. This is for REPORTING PURPOSES ONLY - not needed if you have any one of the listed identifiers below

Facility CLIA Number

Provide the faciliy's CLIA number, where applicable

Facility CLIP Number

Provide the facility's CLIP number, where applicable

Facility NPI

Provide the facility's NPI, where applicable

Facility CAP

Provide the facility's CAP number, where applicable

Organization Address*

Enter the address for the organization named in either "Facility Name" above or "Associated Organization" below.

Organization Phone number*

Enter the phone number for the organization named in either "Facility Name" above or "Associated Organization" below.

Organization Contact Name*

Enter the name of a contact person for the organization named in either "Facility Name" above or "Associated Organization" below.

Contact Name email*

Data System Name

Associated Organization Name*

Name of the organization that operates / maintains the data system for which an OID is being requested.

Associated Organization OID

Associated Organization CLIA

OTC reporter*

Indicate if you are reporting Over the Counter (OTC) At-Home test results.

Select or enter value

Notes

Send me a copy of my responses

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