CAIR Provider Enrollment Form

Site intends to (choose one):

[1] Submit immunization data directly to the CAIR Portal help

[2] Submit immunization data through a Sending Facility (HIO, Vendor data warehouse, your organizations central server, etc.) help

[3] Submit immunization data as a Sending Facility (HIO, Vendor data warehouse, your organizations central server, etc.) for multiple sites. help

Enter the Sending Facility ID of your Data Submitter if known:

Site Information

(Please do not use AOL e-mail addresses)

CAIR Provider ID:

(Please leave CAIR Provider ID field empty)

Site Name:

Current Site NPI:

NPI Number Lookup

Site Address (Line 1):

Site Address (Line 2):

ZIP Code:

Choose Site Type: help

Site Phone:

FAX:

Approximate number of vaccinations anticipated by this Site per month:

Site Contact Information

(Should be person completing registration)

First Name:

Last Name:

Title:

Phone:

Email:

Retype Email:

Responsible Clinician

First Name:

Last Name:

Title:

CA Medical or Pharmacy Lic. Number:

If VFC, please enter VFC PIN number:

Data Exchange Information

What is the name (+version) of the EMR/EHR software used by this office?

Which vendor developed the EMR/EHR software used by this office?

Can this EMR/EHR send HL7 formated data?

Data Exchange/ Vendor Contact Information

DE/Vendor Contact First Name:

DE/Vendor Contact Last Name:

Company:

Position:

Phone:

Email:

Retype Email:

Meaningful Use Info

Is this Site currently participating in the EHR Incentive Program (‘meaningful use’)?

If ‘Yes’ to the above, select your Site’s MU Stage in 2017?

Online Access to CAIR?

As an electronic data submitter, online access to CAIR is not given unless it is requested.
Access to CAIR may be useful to determine what vaccines are due, or to order VFC vaccines (coming soon).

Need Online Access to CAIR?

Please correct the following, and try again.

Please review and correct (if necessary) the data you have entered in this form, then click Continue. To clear the form, press Reset.