eVitals Facility Registration Form

This form is to be used by providers who electronically report live births and deaths to Pennsylvania Registry. Asterisk denotes required field.

Facility Information

Facility name as currently displayed in DAVE/EDRS

Facility Info

Facility's Licensed Name

Doing Business As (DBA) Facility Name. How facility name should be displayed in system and printed on all printed forms.

Facility License #

Facility NPI Number format: 10 digits (xxxxxxxxxx)

Office Type

Facility Name and Address Correction (If Applicable)

Facility Name

Facility Street Number

Facility Street Name

Facility Street Designator

Facility Street Address Line 2

Facility City

Facility County

Facility State

Facility Zip

Facility Tax Identification #

Tax Identification # format: xx-xxxxxxx

Facility Mailing Address

Street Address Line 1

Street Address Line 2

City/Town

State

Zip

Country

Primary Facility Contact *Person responsible for managing the facility’s death reporting users

First Name

Middle Name

Last Name

Email Address

Phone Number

Fax Number

Secondary Facility Contact *Person responsible for managing the facility’s death reporting users

First Name

Middle Name

Last Name

Email Address

Phone Number

Type(s) of Events to be reported (select all that apply):

Birth

Death

Will this facility be ordering death certificates through eVitals/EDRS?

Is your facility a Parent or Child facility? Does your facility/organization own or operate multiple facilities? (parent facility) Or, is your facility owned or operated by a primary external facility? (child facility)

Parent Facility Name if applicable

Child Facility Name if applicable

Authorized Representative

I attest that I am an authorized representative of this facility and that the information I have provided on this form is true and accurate to the best of my knowledge.

First Name

Middle Name

Last Name

Title

Email Address

Phone Number

Date

Click to review Pennsylvania’s eVitals User Agreement and Confidentiality Policy

I have read and agree to the Commonwealth’s User Agreement and Confidentiality Policy

Department of Health

eVitals Facility Registration Form

This form is to be used by providers who electronically report live births and deaths to Pennsylvania Registry. Asterisk denotes required field.

Facility Information

Facility Name and Address Correction (If Applicable)

Facility Tax Identification #

Facility Mailing Address

Primary Facility Contact *Person responsible for managing the facility’s death reporting users

Secondary Facility Contact *Person responsible for managing the facility’s death reporting users

Type(s) of Events to be reported (select all that apply):

Authorized Representative

I attest that I am an authorized representative of this facility and that the information I have provided on this form is true and accurate to the best of my knowledge.

Click to review Pennsylvania’s eVitals User Agreement and Confidentiality Policy

If you have questions or concerns, please contact ra-dhevitalsonboard@pa.gov

This form is to be used by providers who electronically report live births and deaths to Pennsylvania Registry. Asterisk denotes required field. Facility Information

Facility Name and Address Correction (If Applicable)

Facility Tax Identification #

Facility Mailing Address

Primary Facility Contact *Person responsible for managing the facility’s death reporting users

Secondary Facility Contact *Person responsible for managing the facility’s death reporting users

Type(s) of Events to be reported (select all that apply):

Authorized Representative I attest that I am an authorized representative of this facility and that the information I have provided on this form is true and accurate to the best of my knowledge.

Click to review Pennsylvania’s eVitals User Agreement and Confidentiality Policy

If you have questions or concerns, please contact ra-dhevitalsonboard@pa.gov

This form is to be used by providers who electronically report live births and deaths to Pennsylvania Registry. Asterisk denotes required field.

Facility Information

Authorized Representative

I attest that I am an authorized representative of this facility and that the information I have provided on this form is true and accurate to the best of my knowledge.