Solano County

Registration of Intent

Completion of the form below will constitute your registration of intent for Meaningful Use certification. Upon receipt of this form the Solano County HSS will contact you to gather additional information needed to setup your online hub account. Once your organization has been confirmed a questionnaire will be emailed to you with instructions.

Organization:

 

First Name:

 

Last Name:

 

Primary Email:

 
Example: username@organization.com 

Re-enter Primary Email:

 

Secondary Email:

 

Phone Number:

 
Example: 555-123-4567 

Is there more than one Location?


Is your organization interested in meaningful use?


Which meaningful use stage is your organization attesting for?


What is your anticipated attestation date?

       

Which of the following datasets are you interested in reporting data for?






Additional information or questions: