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 request0 of 6 max charactersNotes*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*0 of 2000 max charactersName of Software*0 of 2000 max charactersVendor Point of Contact Name*0 of 200 max charactersWhat Type of Interface is Needed to Send Data?*HL7ExtractOtherInterface – Other*Please describe the data interface required0 of 200 max charactersWhat Type of Data Will Be Included in the Interface Message?*ADTOrdersResultsOtherData – Other*Please describe the type of data to be included in the interface message0 of 200 max charactersHow Many EMR Partners Do You Currently Have?*Please enter a number less than or equal to 10.EMR Partner 1 Name*0 of 100 max charactersEMR 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.0 of 2000 max charactersOther 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. NameThis field is for validation purposes and should be left unchanged.
