2014 Edition Healthcare Registration Form

To register your EHR product, please complete the form below.

Applicant Information

Product Information

Additional Costs
The federal government requires all 2014 Edition technology developers to disclose the types of additional costs (i.e. one-time, ongoing, or both) that an Eligible Provider or Hospital would pay to implement the system’s certified capabilities in order to attempt to meet meaningful use objectives and measures. Actual dollar amounts are not required. Please document any and all types of additional costs that would be incurred (e.g. one-time implementation fee, yearly maintenance charges, etc.).

Gap Certification/Testing
Gap certification enables you to “inherit” the certification from a previous certification and, if approved, exempts you from demonstrating the functional tests in the 2014 Edition program. Please identify the criteria you would like to request gap certification for:

Please provide the time zone where you will be located during your test. If your team will be located in more than one time zone, please select the the time zone we should use for scheduling your test.

Primary Contact

Technical Contact

Marketing Contact

Criteria to be Tested and/or Certified

Clinical Quality Measures–Ambulatory
Identify at least 9 CQMs (6 must be Core) from a minimum of 3 domains:

Clinical Quality Measures – Inpatient
Identify at least 16 CQMs from a minimum of 3 domains

Next Steps

After completing and submitting the registration form, you will be contacted by ICSA Labs as there are two additional documents utilized in establishing a contract for testing. The first is a Master Services Agreement (MSA), and the second is a Statement of Services (SoS). The MSA establishes the business and legal terms of the relationship between our companies, and it is executed once for all future contract documents to utilize. The SoS identifies the products, test services, and fees surrounding a particular transaction. The SoS serves as a formal quotation with the fees and scope of services identified.

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