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).

*E-mail

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 Phone


Mobile 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.

Facility Registration – Registries Available for Applying.png


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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