Tennessee Provider Registration

Full Access
Read Only Access

Select whether the provider is requesting full access (default) or read-only (view-only) access to the application.

Practice Name

Enter the name of the practice. This field is required.

Address

Street Address

Enter the first line of the street address. This field is required.

Street Address 2

Enter the second line of the street address, if necessary.

City

Enter the city name. This field is required.

State

TN is the default state, otherwise select the state from the drop-down list. This field is required.

County

Select the county from the drop-down list. This field is required.

Zip Code

Enter the zip code. This field is required.

Phone

Enter the phone number. An error message will appear if a phone number with repeating digits is entered (e.g., 111-1111). This field is required.

Phone Extension

Enter the extension number associated with the phone number.

Fax

Enter the fax number.  An error message will appear if a phone number with repeating digits is entered (e.g., 111-1111).

Office Manager

Enter the name of the office manager or contact person.

Email Address

Enter the email address for the provider, office manager, or other contact person. This field is required.

Mailing Address (if different from above)

Street Address

Enter or modify the first line of the mailing street address.

Street Address 2

Enter the second line of the mailing street address, if necessary.

City

Enter the city name. (Enter the zip code first to pre-populate the city field.)

State

TN is the default state, otherwise select the state from the drop-down list.

County

Select the county from the drop-down list. (Enter the zip code first to pre-populate the county field.)

Zip Code

Enter the mailing zip code.

Facility Type

Select the Facility type from the drop-down list. If Other is selected, enter a description in the Facility Type Comments field.

Facility Type Comments (if Other)

Enter a description of the Facility Type, if Other was selected from the Facility Type drop-down list.

Facility Type

Does this practice see adults, children, or both?

Select Adult, Pediatric, or Both from the drop-down list. This field is required.

Does this practice provide obstetric care?

Select Yes or No from the drop-down list. This field is required.

Does this practice primarily provide inpatient care, outpatient care, or pharmacy services?

Select Pharmacy, Primarily Inpatient, or Primarily Outpatient from the drop-down list. This field is required.

Is this a multi-specialty group practice?

This question appears if the answer to the previous question is Primary Outpatient. Select Yes or No from the drop-down list. This field is required if it appears on the page.

Select the specialty that best describes this Primarily Outpatient practice.

This displays only if Outpatient is selected. Select a specialty from the drop-down list. This field is required if it appears on the page.

Select the sub-specialty that best describes this ______ practice.

This displays for certain specialties and is a required field if it appears on the page. Select a sub-specialty from the drop-down list.

Has this practice registered for TennIIS access in the past?

Select one of these options (this field is required):

• Yes this practice has registered for TennIIS access every year
• Yes this practice has registered in the past but has not accessed TennIIS in over 1 year
• No this is the first time the practice has registered for TennIIS access
• Don't know

Current Computer Hardware Setup

Internet Access Type

Select the provider office's Internet access type from the drop-down list. Examples:

• Cable modem
• DSL
• T-1

Primary Method of Report

Select the primary reporting method from the drop-down list:

• Direct Data Entry
• DTT Import
• Batch HL7
• Realtime HL7
• Paper

PMS Name

Enter the provider's PMS name.

Name of Vendor/Company

Enter the vendor or company name.

Staff:
  Last Name
  First Name
  Phone
  Email
  Privileges

For each staff member from the provider's office that needs access to the IWeb application, enter their last name, first name, phone number, and email address, and select whether they are to have View Privileges or Edit Privileges. Each field is required for each staff member to have access to the application.

Add More Staff Members

Select this option if you need more rows for additional staff members.

Provider:
  Last Name
  First Name
  Specialty
  Email
  Phone
  Medical License Number

For each authorized immunization provider, enter their last name, first name, specialty, email address, phone number, and medical license number. Each field is required for each authorized immunization provider to have access to the application.

Primary Contact

Type

Select the primary contact type from the drop-down list. Examples:

• Primary Vaccine Coordinator Facility
• Primary Vaccine Coordinator
• Backup Vaccine Coordinator

First Name, Middle Initial, Last Name

Enter the first name, middle initial, and last name of the primary contact person.

Phone Number

Enter the primary contact person's phone number.

Phone Number Extension

If applicable, enter the primary contact person's phone number extension.

Fax Number

Enter the primary contact person's fax number.

Email Address

Enter the primary contact person's email address.