Get Louisiana Electronic Event Registration System User Id Request ... - New Dhh Louisiana

Completing the Louisiana Electronic Event Registration System User ID Request form is an essential step for individuals involved in the registration of vital records. This guide provides clear and supportive instructions to help users easily navigate and fill out the form correctly.

Follow the steps to complete the User ID Request form

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. In Section 1, enter your user information. Fill in your first name, last name, middle name, job title, phone number, and extension. Indicate your role using the available options provided in the checkbox.
3. If applicable, enter your NPI or state license number in the designated field for physicians. Include your funeral home director's license number where required.
4. Moving to Section 2, provide details for each facility you are associated with. For each facility, input the name, type, license number, parish, street address, city/town, and zip code.
5. Read through Section 3, which contains the user agreement for LEERS death registration. Acknowledge your understanding of the agreement's terms and confirm your commitment to comply with DHH guidelines.
6. In Section 4, complete the signatures section. If you are not a physician, coroner, or licensed funeral director, a supervisor must certify your understanding of the agreement.
7. Once all sections are filled out correctly, save your changes and prepare the form for submission. Print the form to obtain required signatures.
8. Submit the completed form by faxing it to (504) 568-8716 or emailing it to LEERS@la.gov.

Complete your Louisiana Electronic Event Registration System User ID Request form online today!