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This registration form is for Utah Eligible Professionals and Eligible Hospitals intending to apply for the Medicaid and/or Medicare EHR Meaningful Use incentive programs–for Stage 1 or Stage 2.

After UDOH receives your registration, your organization's Meaningful Use Contact Person will be contacted and provided instructions for proceeding with the Utah Public Health Meaningful Use process.

All required data (marked with *) must be entered and the form submitted. Incomplete registration forms will not be processed.

General Questions

















Organization Information

** Please enter information about each location for which you plan to attest **
*Name of Organization Location *Location Address Eligible Professional NPI
(If multiple providers, upload spreadsheet below with all NPI numbers.)
Organization Information

** Please enter information about each location for which you plan to attest **
*Name of Organization Location *Location Address Eligible Hospital CCN
Immunization Information











Electronic Lab Reporting Information


Syndromic Surveillance Information




Current EHR System(s)
Data Collected *Vendor Name *Product Name *Product Version *Is EHR Product ONC-certified?
Immunizations:
Electronic Lab Reports:
Syndromic Surveillance:
Note: To qualify for the EHR Meaningful Use Incentive Program, your EHR System must be certified. A complete list of certified products can be found at: http://onc-chpl.force.com/ehrcert

Contact Us

Utah Department of Health
Bureau of Epidemiology
801-538-6191
Fax: 801-538-9913
288 North 1460 West
PO Box 142104
Salt Lake City, Utah 84114-2104

24-Hour Urgent Event & Disease Reporting

1-888-EPI-UTAH (374-8824)
 

Regular Business Hours:

Monday - Friday
8:00 a.m. - 5:00 p.m.

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