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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.   Dr Mr Ms Miss Mrs *First Name   *Last Name   *Title:   *Department:   *Facility Name:   *Address 1:   STREET ADDRESS ONLY Address 2: PO BOX, BUILDING, MAILSTOP, ROOM/SUITE NUMBER *City:   *State: Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming   *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

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