Interface Enrollment Request Form  
  Before you complete the form below, please click here to review guidance on establishing an electronic interface with NJIIS.  
Practice Information
Practice Name:
Are you currently using NJIIS? NJIIS Provider ID: Practice VFC PIN (if applicable):
Practice Physical Address 1: Practice Physical Address 2:
State: Zip:
Contact Last Name: Contact First Name:
Title: Email:
Phone: Fax:
--   Ext --
Practice Type: Specialization:
Reason for enrollment
Note: If your reason for enrollment is "Meaningful Use Objective (Stage 1 Attestation Only)," NJIIS will not implement a production interface for your practice.
Approximate number of vaccines administered in your practice per year [Please provide accurate numbers as these will be used as a baseline to evaluate your transmissions.]
Note: If you selected "None", please apply for the exclusion for MU attestation. You do not need to submit this request form for NJIIS interface. NJIIS does not process interface enrollment forms for practices that do not administer vaccines.
Number of patients under 7 years of age seen at the practice
Vendor Information
Please select NJIIS established vendor from the list or type the new vendor name.
Vendor Name: Software Name:
Contact Last Name: Contact First Name:
Phone: Email:
--   Ext
Interface Information
Interface Type:  (If not sure, check with your EHR vendor.)
File Format: HL7 Version:
Note: HL7 2.5.1 is the required standard for web services.
Purpose of Enrollment    
To read more about bi-directional messaging, click here.
Other Information
Submitted By:

This system is restricted to authorized users. Random audits are routinely performed.
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