Louisiana Syndromic Surveillance - Registration of Intent for Hospital Emergency Departments and Urgent Cares
Please use this form to register your intent to participate in Syndromic Surveillance if you represent a hospital with an emergency department or an urgent care facility. Other providers are not eligible for syndromic surveillance in Louisiana at this time and can claim an exclusion from the meaningful use objective.

If you represent a hospital system with more than one eligible emergency department or urgent care, please submit a registration form for each facility.

Upon completion, you will receive an email acknowledgment of your registration within 5 business days. Please contact Jenna Iberg Johnson with any questions: jenna.ibergjohnson@la.gov or 504-568-8312.

Are you registering intent for a hospital emergency department or urgent care?
If your answer is no, you are not eligible for syndromic surveillance in Louisiana at this time - you do not need to register and can claim an exlcusion
Facility Name
Your answer
Facility Address
Your answer
Facility City
Your answer
Facility Zip Code
Your answer
Facility Parish
Your answer
Facility National Provider Identifier (NPI)
Your answer
Primary Facility Contact Name
Main contact for coordinating communication between the facility and the state
Your answer
Facility Contact Phone
Your answer
Facility Contact Email
Your answer
Primary Technical Contact
Main contact who will be working with the state during testing and validation processes.
Your answer
Technical Contact Phone
Your answer
Technical Contact Email
Your answer
Will you be submitting data via LaHIE, the state-designated health information exchange?
Which MU Stage are you preparing for?
When is your MU Reporting Period?
Your answer
When do you plan to submit a test file?
This does not need to be a finalized date
Your answer
In which incentive program(s) are you enrolled?
Are you using certified EHR technology for syndromic surveillance submissions?
Who is your EHR Vendor?
Your answer
EHR Product and Version
Your answer
Health organization affiliation, if any
Your answer
Additional comments:
Your answer
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