PA-ELR Laboratory Registration Form

Directions for completing form:
  1. Provide all information and answers to the questions. Note: incomplete forms will not be processed.
  2. Questions please contact the Help Desk at (717) 783-9171.
Please note that completing this registration form is the first step of the process to gain access to PA-NEDSS and PA-ELR. Once you have completed and submitted this form you will be contacted by the PA-NEDSS Team to continue the process. You will not be automatically granted access to PA-NEDSS and PA-ELR by completing this form only.


SECTION 1: ORGANIZATIONAL INFORMATION


ORGANIZATION's MAILING ADDRESS

Organization Name: (Include Health System Name if applicable)

Address Line 1:

Address Line 2:

City : State: Zip:

Phone: ex. (999) 999-9999 x999


CLIA ID:


NPI:


LABORATORY CONTACT INFORMATION

Lab Contact Name :

Lab Contact Title :

Lab Contact Phone: ex. (999) 999-9999 x999

Lab Contact Email:


ORGANIZATION'S INFORMATION TECHNOLOGY CONTACT INFORMATION

IT Contact Name :

IT Contact Title :

IT Contact Phone: ex. (999) 999-9999 x999

IT Contact Email:

Which exportable data format(s) can your System generate? (check all that apply)
HL7 v2.3
HL7 v2.3.1
HL7 v2.5.1
Comma Delimited
Other (Please Specify)

Which Standard Code Sets does your system utilize? (check all that apply)
LOINC
SNOMED
HL7
ISO+ (ISO Customary Units)
UCUM (Unified Code for Units of Measure)
Other (Please Specify)

Please indicate in the table below the type of test(s) and estimated volume(s) your organization will report through PA-ELR (at least one is required.)

Type of Tests  Estimated Number of Test Results
Infectious Diseases Per
STD Per
Lead Per
HIV Per
TB Per
Other Per
If "Other" please specify



Is your organization onboarding to meet Meaningful Use requirements?
Yes No

If you answered yes you must complete Section 2 Meaningful Use, otherwise proceed to Section 3.

Section 2: Meaningful Use

  1. If your facility is onboarding for the purposes of Meaningful Use this section must be completed.
  2. A separate registration form must be completed for each facility that will attest for Meaningful Use compliance.
  3. The expectation of the Pennsylvania Department of Health (DOH) is regardless of the Meaningful Use stage that an organization is attesting, once the onboarding process starts the organization commits to working towards ongoing submission. If an organization begins the process and does not follow through to ongoing submission, that organization will be placed back in the onboarding queue and resuming the onboarding process will be prioritized by the DOH.
Meaningful Use registrants will automatically be placed in the PA-ELR On-Boarding Queue. Meaningful Use registrants will be contacted at PADOH's discretion to begin the ELR onboarding process. Meaningful Use registrants have 30 days to comply with the PADOH request to proceed or the registrant will be placed back in the PA-ELR On-Boarding Queue. Failing to respond to PADOH's request to proceed may impact the facility's Meaningful Use compliance status.

Is your organization currently or planning to submit ELR messages through an HIE?
Yes No
If Yes, Regional HIE Name:

Is your organization currently submitting messages through ELR in a non-Meaningful Use compliant format?
Yes No

Which Meaningful Use Stage is this your organization onboarding for?
Stage 1
Stage 2

What certified technology will generate the MU compliant message?
Vendor:

Version:



Section 3: Technical Requirements

Which operating system does the computer (desktop PC or server) that will be sending ELR data to the PA Department of Health run under?
Windows (Please Specify)

Unix/Linux (Please Specify)

Other (Please Specify)


Which version of Microsoft .NET Framework is installed?

Which web browser is installed?

Is a Proxy Server in use?
Yes No

Is a Static IP assigned to the PC/Server?
(If "Yes", the Static IP address will need to be added to your firewall exceptions list.)

Yes No

Are Firewall rules used to gain access to the internet?
Yes No