Integration Interoperability Request What Would You Like To Do?* Create a New Cures Act Request Manage Existing Request Reference ID*Please enter the reference ID from your existing requestNotes*Please enter notes related to your request hereClient Business InformationCompany Name*Company Phone Number*Company City*Company State*Company ZIP Code*Company Point of Contact Name*Company Point of Contact Phone Number*Company Point of Contact Email Address* Information About Software to InterfaceSoftware Vendor*Name of Software*Vendor Point of Contact Name*What Type of Interface is Needed to Send Data?*HL7ExtractOtherInterface – Other*Please describe the data interface requiredWhat Type of Data Will Be Included in the Interface Message?*ADTOrdersResultsOtherData – Other*Please describe the type of data to be included in the interface messageHow Many EMR Partners Do You Currently Have?*Please enter a number less than or equal to 10.EMR Partner 1 Name*EMR Partner 2 Name*EMR Partner 3 Name*EMR Partner 4 Name*EMR Partner 5 Name*EMR Partner 6 Name*EMR Partner 7 Name*EMR Partner 8 Name*EMR Partner 9 Name*EMR Partner 10 Name*EMR Partners Upload*Please upload a file containing the names of any additional partners not listed aboveAccepted file types: doc, docx, pdf, Max. file size: 15 MB.PHI Security Measures Taken*Please describe the specific measures you have taken to ensure any patient information is and will continue to be protected.Other DocumentationPlease upload any additional documentation applicable to your request Drop files here or Select files Accepted file types: doc, docx, pdf, txt, msg, zip, Max. file size: 15 MB. PhoneThis field is for validation purposes and should be left unchanged.
