Purpose
The Facility Information Form records essential contact and facility characteristic information for each physical location from which you will submit data to the NRDR.
Completing the Form
The form opens after you create your corporate account. Click the Add New Facility button and enter data for each field described in the tables below. At the end of the process, a unique facility ID is created.
Fields marked with an asterisk are required.
Facility Information
For detailed definitions of facility characteristics, click here.
Field | Description |
|---|---|
*Facility Name | The Facility name must be between 2 and 45 characters long. The first two characters must be from the letters “A-Z” or “a-z”. |
*Facility Category | Select the appropriate category from the drop-down menu. If you select Other an additional field will appear with the message Please enter your facility category below. Enter free-form text describing your category in the field provided. |
*Location | Select the approximate population size of the facility’s location. |
*Trauma Center Level | Select the appropriate value from the drop-down list. |
*Street Line 1 | This field must be less than or equal to 45 characters; at least 1 character must be "A-Z", "a-z" or "0-9"; the rest can be any character. |
Street Line 2 | This field is optional and must be no more than 45 characters. |
*City | This field must be 2 to 45 characters long. It cannot include special characters other than a word's hyphen (“-“). |
*Country | Select the appropriate response. |
State or Province | This field is required for addresses in the United States or Canada. |
*ZIP or Postal Code | Enter the ZIP or postal code for your primary contact address. |
*Telephone | Enter a primary contact telephone number. |
Facility NPI | The National Provider Identifier is required if the facility intends to use the LCSR for Medicare reimbursement; it is optional for all other registries. If entered, it must be exactly ten digits. |
NMD-Certified Vendor | Required only if your facility will use the NMD registry. |
Facility Administrator Information
Each facility must have one Facility Administrator. This can be the same person as the Corporate Account Administrator if desired. If the Facility Administrator is someone other than the Corporate Account Administrator, the application process sends an invitation for the person to create an NRDR user account as the Facility Administrator.
Field | Description |
|---|---|
*First Name*Last Name | The Facility Administrator's first and last names must be between 2 and 45 characters long. Names must include at least 2 characters from the characters "A-Z", "a-z" or " ' " (apostrophe). The remaining characters can be any of the characters "A-Z", "a-z", " ' " (apostrophe) and "-" (hyphen). |
Enter the e-mail address you want the NRDR system to use for communication. This address will be the email point of contact. | |
*Confirm E-mail | Enter the e-mail address again to confirm there are no typos. |
Title | Enter a title, if desired |
*Office PhoneMobile Phone | Enter the phone numbers of the facility administrator. |
Address | Enter the contact address. Note that this is a free-text field for your use and will not be used for official communications by the ACR. |
Available Registries
Select one or more registries to which the facility will submit data.
After you have entered all information for the physical facility and facility administrator and selected registries, you can create another facility account by clicking the Add New Facility button at the top of the page, or you may advance to the next section by clicking the Next button at the bottom of the page.
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