Public Health Gateway Provider Registration Form

Eligible Hospitals and Critical Access Hospitals (CAHs) must submit Electronic Laboratory Reports (ELR) as a core item in order to meet meaningful use requirements. This form should be completed and submitted to indicate intent to initiate Electronic Laboratory Reporting with the Texas Department of State Health Services.

Are you registering your intent with DSHS to initiate electronic laboratory reporting?

Legal Business Name of the facility that will be reporting ELR
CLIA Number of Reporting Facility
Address of Reporting Facility*
City*
State*
ZIP*
Primary Contact Name*
Primary Contact Phone Number (with area code)*
Extension*
Primary Contact E-mail Address*

Number of Reporting Facilities that will be included in this interface(DSHS will contact the Primary Contact at your facility for additional information, which will include the Name and CLIA number of all additional facilities)
Name of EHR Software used to report data
Vendor Name
Product Name
Software Version  

Can your system create HL7 version 2.5.1 messages?

Most Frequently Reported Tests currently performed at the Reporting Facility (separate by a comma)  

It is recommended that your facility include test results sent to a reference laboratory for testing. Will your facility be including those results in this ELR interface?