Cameron County Department of Health and Human Services Meaningful Use Stage 2 Eligible Professional Registration Form

All Eligible Providers who qualify and intend to submit electronic data to the Chronic Disease Registry must register their intent by completing and submitting this form. The deadline for EPs in Cameron County to register for the 2015 Meaningful Use reporting period is February 25, 2015 and this specific program participation is limited to Eligible Providers in Cameron County only.

Eligible Provider MU 2 Registration

Date

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Facility Name (required)

Facility Location (required)

Facility City (required)

Facility State (required)

Facility County (required)

Cameron County Only

Facility Zip Code (required)

Primary Contact Name (required)

Primary Contact Phone Number (required)

Primary Contact Email address (required)

Provider Name (required)

Provider Type (Specialty) (required)

Individual NPI (required)

Current MU Stage (required)

MU Stage 1

MU Stage 2

Incentive Program Enrolled: (required)

Medicaid

Medicare

E.H.R. Vendor (required)

E.H.R. Vendor Type

Local Server Cloud-Based 3rd Party Unknown

E.H.R. Product and Version Number

Additional Information

Type the characters (required)

This field should be left blank

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After registration has been validated, you will receive a confirmation letter or, if needed, a request for additional information from the RGV HIE. Questions regarding this process may be addressed to Janie Martinez, Project Manger, via email at janie@old.rgvhie.org.