ERP Setup Form
Thank you for choosing the American Diabetes Association for Recognition of your Diabetes Self-Management Education Program.
Once this form has been submitted and approved, the Quality Coordinator will receive an email communication with the Service ID# along with the login details to the ERP Portal.
* indicates a required field.

Sponsoring Organization Information:
Sponsoring Organization Name*:


Sponsoring Organization Administration Officer Information:
Name*:


Title:


Email*:


Phone*:


Fax:


Address 1*:


Address 2:


City*:


State*:


Postal Code*:


ERP Quality Coordinator Information:
First Name*:


Last Name*:


Title:


Email*:


Phone*:


Address 1*:


Address 2:


City*:


State*:


Postal Code*:


Misc Questions:
Does your service plan to use Chronicle Diabetes?:


Review the Chronicles Diabetes here

Do you plan on a Non-ADA Recognized Chronicle Subscription?:


Review the Benefits of a Non-ADA Recognized Chronicle Subscription here

How did you hear about the ADA Education Recognition Program?:


Additional Comments:


Return to Login Screen
This site is protected by Trustwave's Trusted Commerce program