Hawaii Department of Health: eCR Registration

This form will serve as your Registration of Intent for Electronic (Initial) Case
reporting eICR to the Hawaii Department of Health (HDOH). You should only register here, if the following criteria apply:

- You are registering for Meaningful Use Stage 3 (not Stage 2)
- You already have a certified eICR product installed within your EMR and are
ready to send test data.

Please note: this registration will only be valid for 30 days. Within 30 days of
registration, you must complete a second survey. This will be sent to your confirmation email, indicating the volume of reportable case data you need to report annually to HDOH.

Thank you!

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* 1. Registration Status

New

Update

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* 2. Is this registration for Meaningful Use (MU) Stage 3?

Yes

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* 3. What is your MU Stage 3 start date for attestation?

Date / Time

Date

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* 4. Provider Type

Eligible Hospital (EH)

Eligible Provider (EP)

Eligible Clinic (EC)

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* 5. Do you currently have a Certified eICR Product?

Yes

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* 6. What is the vendor of the eICR product?

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* 7. What is the product name and version number?

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* 8. What is the ONC certification number?

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* 9. What eICR format will you be submitting?

eICR HL7 standard

CDA HL7 standard

Flat or text file

Other

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* 10. Are you registering as a single provider or multiple providers

Single

Multiple

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* 11. Point of Contact: Name, Address, Email, Phone #

Name *

Company

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 12. Point of Contact: Position/Title

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* 13. Secondary Point of Contact: Name, Email, and Phone #

Name

Email Address

Phone Number