Indiana State Department of Health
Promoting Interoperability
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Register Organization:
Each physical location is deemed a facility.
Your Organization is NOT a facility, but the parent company of the facility.
Note: Fields with an asterisk (
*
) are required.
*
Organization Name
*
Primary Contact Title
*
Primary Contact First Name
*
Primary Contact Last Name
*
Primary Contact Phone
*
Primary Contact Address
*
Primary Contact Zip Code
*
Primary Contact Email Address
*
Password
Must be at least 8 characters
Must contain at least one one lower case letter,
one upper case letter, one digit and one special character.
Valid special characters are @#$%^&+=*!
Req
*
Confirm Password
The Password and Confirmation Password do not match.