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Tuesday, September 07, 2010
   
Enhanced Information Dissemination & Collection (EIDC) User Account Request

The following information is required to obtain secure access to EIDC. By submitting this request, you swear or affirm that you are authorized to perform business processes for the facilities listed below.
  1. First Name:*

  2. Last Name:*

  3. Title:*

  4. E-mail Address:*

  5. Reason for request (at least one reason is required):*

  6. Technical Issue Description:

  7. Please identify the type of entity with which you are affiliated (at least one type is required)*

    8.  
    Facilities or Hospitals to Associate with this account
     
  8. Facility, Hospital, or Program Name:*

  9. Address:*

  10. City/State/Zip:*

  11. State ID, Hospital, or Program Number:*

  12. Facility, Hospital, or Program Name:

  13. Address:

  14. City/State/Zip:

  15. State ID, Hospital, or Program Number:

 

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All information is strictly CONFIDENTIAL