2019-303-E Emergency Svc - NCHIEA participation agreement

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51 Attachment 11 NC HealthConnex Diabetes Registry Registration Form Please complete this document if you would like to demonstrate your intent to submit data to the NC HealthConnex Diabetes Registry operated by NC HIEA in collaboration with the NC DHHS Division of Public Health. The Diabetes Registry is a tool for tracking the clinical care and outcomes of the patient population in North Carolina diagnosed with or presenting signs or symptoms of Diabetes. Data included in the registry will be important in assisting clinicians, the State, and other health care stakeholders with appropriate preventive maintenance and disease management. This registry will assist your organization and your providers to meet Meaningful Use (MU) objectives, and it should be available in mid-2018. In order to support your organization’s MU attestation, your organization will need to send out the Diabetes Registry active engagement emails to each health care provider who is participating in the MU disease registry objective. This is an important step so that individual providers can reference the registration confirmation emails in future audits by NC Medicaid or the Centers for Medicaid and Medicare Services. If you sign this form, you will receive three emails from NC HIEA. Please forward these emails to participating providers. You will need to refer to these communications if your organization or your health care providers are audited after attesting to Meaningful Use. The emails you should receive are as follows: 1. Registration Email: This email will demonstrate your active engagement with the Diabetes Registry by stating that you have registered your intent to contribute to the Diabetes Registry. 2. Testing and Validation Email: This email will confirm that you are in the testing and validation process with NC HealthConnex. 3. Live-In-Production Email: This email will state that you are submitting data to NC HealthConnex, and that relevant data elements pertaining to patients’ diabetes diagnoses, treatments, test results, etc., will be captured and stored in the Diabetes Registry. Contact Person for Emails Regarding the Diabetes Registry: Name: Title: Email: Please sign below if you would like to demonstrate your intent to show active engagement with the NC HealthConnex Diabetes Registry operated by NC HIEA in collaboration with the NC DHHS Division of Public Health Participant Organization Name: By: Authorized Signature Name: Title: Date: *Please note, all data submitted to NC HealthConnex pertaining to a patient diagnosed with or showing signs of diabetes may be included in the Diabetes Registry regardless of whether this attachment is signed. 3OHDVHQRWH5HJLVWUDWLRQLQWKH'LDEHWHV5HJLVWU\LVYROXQWDU\,I\RXGRQRWSDUWLFLSDWHLQ0HDQLQJIXO8VHRU RWKHULQFHQWLYHSURJUDPVSOHDVHGLVUHJDUGWKHIROORZLQJIRUP Kyle Ronn Quality Assurance Coordinator kronn@orangecountync.gov Orange County Emergency Services Dinah Jeffries Emergency Services Director DocuSign Envelope ID: 47B4445A-C7CA-4D2E-9075-2AFD82F82DEC