NCDR™ CARE Registry™ - Information Request Form

Administration

Reports

Data

Resources

CARE Registry™

Elements/ Definitions

Sample Reports

Software Vendors

Research

IC³ Program™

CathPCI Registry™

ICD Registry™

ACTION Registry® - GWTG™

Request For Information

To help us appropriately respond to your request, please complete and submit the following form.
(NOTE: Fields marked with an asterisk [*] are required.)

NCDR^® Participant ID:
(if applicable)

The NCDR Participant ID is a unique 6-digit identifier assigned to participants when they enroll in an NCDR registry.

Promo Code:
(if applicable)

The Promo Code is a 6-digit alpha-numeric code that you can find near www.ncdr.com on the promotional piece you received, e.g., B07298

NPI Number:
(if applicable)

The National Provider Identifier (NPI) number is a unique 10-digit, numeric identifier assigned by CMS to covered health care providers. The intelligence-free numbers do not carry other information about the provider, such as the state in which they practice or their medical specialty.

	*First Name		*Last Name

*Title:			*Department:
*Facility Name:
*Address 1:	STREET ADDRESS ONLY
Address 2:	PO BOX, BUILDING, MAILSTOP, ROOM/SUITE NUMBER
*City:		*State:		*Zip:
*Phone and Ext:	INCLUDE AREA CODE	Fax:	INCLUDE AREA CODE	*Email:
NCDR does not currently provide registry services to facilities outside the U.S.

TYPE OF REQUEST:
Check all that apply:	Information Packet CARE Registry Program Summary, CARE Registry Fact Sheet, Cardiosource Information Enrollment Packet Instruction page, contact information form, contracts and/or addenda as appropriate

INTEREST IN NCDR: Please rate your level of interest in:
ACTION Registry™	1 (low) 2 3 4 5 (high) Participant
CARE Registry™	1 (low) 2 3 4 5 (high) Participant
CathPCI Registry™	1 (low) 2 3 4 5 (high) Participant
ICD Registry™	1 (low) 2 3 4 5 (high) Participant

Why are you interested in participating in an NCDR registry? (Check all that apply)
	To measure and improve the quality of cardiovascular care in our facility
	To benchmark our practice patterns against national averages and volume-based peer comparison groups
	Because NCDR is the gold standard of national cardiovascular data registries
	For full access to the wide range of NCDR quality improvement and knowledge assessment tools
	In response to the dynamics of today's healthcare environment, e.g., federal, state, or payer mandates; P4P; PQRI, etc