NCDR™ CARE Registry™ - Information Request Form

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CARE Registry^®

About the Registry

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Elements and Definitions

Software Vendors

ACTION Registry^® - GWTG™

CathPCI Registry^®

ICD Registry™

IMPACT Registry™

PINNACLE Registry™
(IC³ Program^®)

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., B09298	Hospital/Practice 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 for the purpose of submitting claims.

	*First Name		*Last Name		Credentials

*Title:			*Department:
*Facility Name:
*Address 1:	STREET ADDRESS ONLY
Address 2:	PO BOX, BUILDING, MAILSTOP, ROOM/SUITE NUMBER
*City:		*State:		*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.

PLEASE SEND ME MORE INFORMATION ABOUT THESE NCDR REGISTRIES (Select all that apply):
ACTION Registry^®–GWTG™
CARE Registry^®
CathPCI Registry^®
ICD Registry™
IMPACT Registry™
PINNACLE Registry™(formerly the IC³ Program^®)

Why are you interested in participating in an NCDR registry? (Check all that apply)
To measure and improve the quality of care in your facility
To streamline the reporting requirements of your corporation, or meet federal/state mandates


To ensure optimal reimbursement from CMS or other P4P initiatives

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