Fillable Michigan Care Improvement Registry (MCIR) Provider Site Usage (Michigan Care Improvement Registry)

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Michigan Care Improvement Registry (MCIR) Provider Site Usage (Michigan Care Improvement Registry)

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Michigan Care Improvement Registry (MCIR)
Provider Site Usage Agreement
In accordance with Public Act 540 of the Public Acts of 1996, Amended 2006 as Act 91, and codified as MCL 333.9201 et seq. of the Michigan Public Health Code, the
Michigan Department of Health and Human Services (MDHHS) has established the Michigan Care Improvement Registry (MCIR) to record and to access information regarding
administered immunizations and other health related data by health care providers. Users of the system must refrain from employing the MCIR and data on the MCIR for any
other use. Access to the MCIR database is permitted only under part 92 of the public health code. Access to MCIR data is under the terms and conditions prescribed by the
MDHHS. Improper use of the MCIR will result in revocation of the user’s access privileges and potential liability
under MCIR, Vital Records, and Michigan Computer Crime
Laws. The MDHHS reserves the right to revoke a user’s access privileges at any time, without notice.
Any health care provider, defined as those who can authorize the administration of an immunizing agent or adding other health related data (as defined in Public Health Code
MCL 333.9204), may use this form to register to use the MCIR. Please read the following statements. If you agree to abide by these statements, please complete the
information requested below and return this agreement to the appropriate regional office: https://www.mcir.org/providers/regional-coordinators/contact-regions/
As a user of the Michigan Care Improvement Registry I accept and agree to the following:
I will handle information or documents obtained through the MCIR in a confidential manner.
I will restrict my use of the MCIR to accessing information and generating documentation only as necessary to properly conduct the administration and
management of my duties as they relate to immunizations and other health related data.
I understand that my transactions on the MCIR are logged and are subject to being audited.
I will not furnish information or documentation obtained through the MCIR to individuals for personal use nor to any individuals not directly involved
with the conduct of my duties as they relate to immunizations and other health related data.
I will not alter or falsify any document or data obtained through the MCIR.
I will not attempt to copy all or part of the database or the software used to access the MCIR database in any unauthorized fashion, nor attempt to falsify
or otherwise alter data in the MCIR database or otherwise violate the Michigan Computer Crime Law (MCL 752.794 - 752.797)) or the Vital Records
Law (MCL 333.2894) summarized on the reverse side of this form.
I will carefully safeguard my access privileges and password for the MCIR and will not permit their use by any other person.
I will report any threat to or violation of the MCIR security.
I will enter immunization encounter information for all immunizations provided to children born after January 1, 1994 (effective when I receive MCIR
access).
I will strive to enter accurate and timely data into the MCIR within 72 hours from date of administration of an immunization as set forth in
Administrative Rule 325.163(6).
MCIR data may not be used for research purposes without approval by the MDHHS Institutional Review Board (www.michigan.gov/irb). Refer to
Admin Rule R 325.9055
Provider Information (Please print or type):
Please select one of the following five options and complete the form below:
I would like to be granted access rights to MCIR.
I would like to renew my access rights to MCIR (Every three years a renewal MCIR application must be submitted to the MCIR regional office (visit
https://www.mcir.org/providers/regional-coordinators/contact-regions/
for contact information.)
I would like to change information in my existing MCIR User/Usage Agreement. Please enter your SITE NUMBER: ______________________________
I would like to discontinue use of my MCIR SITE. Please enter your SITE NUMBER: ______________________________
I would like to merge my SITE NUMBER: __________________________ with this SITE NUMBER: __________________________________
I am registering as a (Check One): Public Provider Private Provider
I am registering as a (Check One): Family Practitioner Pediatrician Internist
OB/GYN other: (specify) _____________________________________________
I am registering as a: Site Administrator
I have read the above security agreement and the prohibited acts provided on the reverse side of this form. I understand this
information and I agree to comply with the above provisions. Further, I understand any violation of these provisions may result in
termination of access privileges and/or recommendation for prosecution.
Please complete the following information: PLEASE PRINT or TYPE
Applicant’s Full Name
Organization/Practice Name
Supervising Physician’s Full Name and Degree:
Supervising Physician’s License # and Issuing State:
Facility
Address:
Street
City
State
County
Phone #:
/
Fax #:
/
(REQUIRED) Applicant’s E-Mail Address:
Supervising Physician
Date Signed:
August 26, 2019
Instructions for Completing the MCIR Provider User/Usage Agreement
You must complete this agreement and submit it to your Regional Coordinator for approval before gaining access to
the Michigan Care Improvement Registry (MCIR). Follow the instructions below to complete the MCIR Provider
User/Usage Agreement.
Step One: Read the Agreement
Carefully read the first two paragraphs of this agreement, including the bulleted list of statements at the top of the
form, so that you completely understand the confidentiality regulations, restrictions, and requirements for using the
MCIR. Complete text for the laws, acts, and provisions cited in these passages is included with this agreement for
your reference.
Step Two: Select one of the three options which define your intent for using this Form
1. You may request access to MCIR.
2. You must renew your MCIR access rights every three years according to MCIR legislation. A new user
agreement must be submitted to the MCIR regional office.
3. You may change information you submitted on your previous MCIR User/Usage Agreement. You will
need to enter your current SITE ID here, as well.
4. You may request to have your site disabled. You will need to enter your current SITE ID on the form.
The SITE ID is located under My Site tab. Then proceed to Edit My Site link. SITE ID is located in the top
right corner of the page.
5. You may request to have a MCIR SITE ID merged with another MCIR SITE ID (example clinic merger,
retired physician)
Step Three: Register as a Public or Private Provider
Under the Provider Information heading, specify whether you are registering as a public or private provider:
Check Public Provider if you are primarily employed by a public health department; or
Check Private Provider if you are primarily employed within the private sector.
You may check only one option.
Step Four: Register as a Specialty Designation
Specify the specialty designation under which you are registering. The choices are: (You may check only one of
these options.)
Family Practitioner
Pediatrician
Internist
OB/GYN
Other (please specify in the space provided).
Site Administrator: Staff person who is responsible for registering and monitor MCIR User accounts for the
organization.
Step Five: Entering Site Demographic Data
Applicant’s Name: May be Supervising Physician or Site Administrator
Organization: Practice Name
Enter Organization/Practice Name as well as the full name and title of the designated Medical Officer on the lines
provided.
Step Six: Sign and Deliver the Agreement:
The Medical Officer specified in Step 5 should sign and date this agreement and send it to the address identified
in paragraph two of the MCIR Provider User/Usage Agreement. Any issues or questions regarding confidentiality
or the appropriate use of the MCIR by the members or staff of the registered organization or practice are the
responsibility of the Medical Officer specified in Step 5.
This document is subject to revision or withdrawal at any time at the discretion of the Michigan Department of Health and Human Services.
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Completed 3 June 2021

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