ONC Cures Act Data Request Form
First Name
Last Name
Phone Number
Email
Date
Please describe, in as much detail as possible, what you are requesting including the population of patients and timeframe needed:
What is the relationship to the patients whose records are being requested? (for example, provider/patient relationship)
What is the purpose of the requested information/how will it be used?
How would you like to receive the information? (ie: flat file, CCD exchange)
Additional Comments
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