California Cancer Registry - AB2325 Electronic Pathology Registration

Instructions:

Pathology labs and/or facilities are required to register for reporting on behalf of represented pathologists within an organization or lab. Please fill in the follwing registration information that includes specific contact information, inclusive of a lead physician contact, lab management contact, and a technical interface contact, as well as LIS and/or EHR vendor information for the purpose of onboarding.

Organization Name:    
Number of Represented Laboratories:    
Number of Represented Pathologists:    
Lead Laboratory Management Contact
Title:  
First Name:    
Last Name:    
Email:
   
Phone:  
Lead Physician Contact
Title:  
First Name:    
Last Name:    
Email:
   
Phone:  
Lead Technical Contact
Title:  
First Name:    
Last Name:    
Email:
   
Phone:  
Represented Pathologist
First Name:   Last Name:   CA Physician License Number:  
Represented Laboratory
Name:     CLIA:    
Data Submission Method
Vender Information(500 characters max, EHR, LIS, Interface Engine etc)