Healthcare Provider CDS Verification Form
Please complete this form to verify your organization’s CDS setup and use-case readiness. All fields are required for verification.
Organization Name
*
Primary Contact Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
CDS Platform or Vendor Used
*
Which best describes your CDS use case?
*
Please Select
Medication Safety
Order Sets/Pathways
Diagnostic Support
Clinical Reminders
Other
Briefly describe your CDS use case or scenario
*
Current CDS Implementation Status
*
Planning
In Progress
Live/Operational
Anticipated Go-Live or Update Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments or Notes (optional)
Submit Verification
Should be Empty: