Get Asiis Enrollment Form Web Based Application For Health ... - Azdhs

The ASIIS Enrollment Form is essential for health workers needing to register for the Arizona State Immunization Information System (ASIIS). This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete the enrollment form successfully.

1. Press the ‘Get Form’ button to acquire the ASIIS Enrollment Form. Ensure that the form opens correctly for editing.
2. In the 'Facility Name & District' section, enter the official name of your facility, along with its corresponding district to ensure proper identification.
3. Fill in the 'Contact Name' field with the name of the primary contact person for your facility. This individual should be someone familiar with the immunization records.
4. Complete the 'Address', 'City', 'State', and 'Zip Code' fields to provide your facility's location accurately.
5. Input the phone number and fax number for the facility within their respective fields to facilitate communication.
6. Include an email address where notifications or information regarding immunizations can be sent to ensure efficient communication.
7. After entering the required information, list all staff members who require web access to the ASIIS system. Ensure that each entry is properly documented.
8. Review the agreement section and ensure it is signed by an authorized representative. This signature confirms compliance with the ASIIS confidentiality policy.
9. Once all sections are filled, you may save any changes made. The form can then be downloaded, printed, or shared as needed.

Complete your ASIIS enrollment form online to ensure seamless access to immunization records.