Register Intent for CPCI Specialized Registry- Azara Healthcare

Name

Email address

Phone number

Name

Email address

Phone number

Practice Name

Practice Address

City, State, and Zip Code

Practice NPI #

Provider First and Last Name

Provider Email Address

Provider NPI #

Provider CMS Registration ID #

Incentive Program (Medicaid or Medicare)

Meaningful Use Stage

Meaningful Use Year #

Meaningful Use reporting period start date

Meaningful Use reporting period end date