New Jersey Immunization Information System

SITE ENROLLMENT REQUEST:

EARLY HEARING DETECTION AND INTERVENTION PROGRAM

The following information is required to set you up as an NJIIS Site and Provider; please fill out this form completely.

Fax the completed form to the Early Hearing Detection and Intervention Program at 609-633-7820 or send via email to EHDI@doh.state.nj.us.

County:	Provider Name:
Site Name:
Site Administrator:	Telephone No.:
Site Address:
City, State, Zip Code:
Signature:
(PRINT the name you would like to appear as this provider’s signature on the reminder/recall notices i.e. Dr. Bonnie Smith, MD, etc.)
Type of Facility (Check (() only one):

Hospital Audiology Facility

Other Audiology Facility

ENT Office
Other:
List the names of all the users from your site who will need access to this provider:
1)	4)
2)	5)
3)	6)

For Internal Use Only

Faxed: _______________________________	Received: ____________________________

NJIIS Admin Done: _____________________	Signature: ____________________________

IMM-34

MAY 13

IMM-34, Site Enrollment Request - Early Hearing Detection and Intervention Program

IMM-34, site enrollment request, enrollment request, new sites, early hearing detection and intervention program, EHDI program, EHDI, NJIIS

EWhite

2006-09-06

NJDHSS