Center for Health Information and Research

Service Request Form

Please review our policies and procedures before submitting this form.

Name/Organization
Ex. Date range, demographic, clinical restrictions, specific field names. Specify if criteria is at the individual patient level, claim level, visit level or other level.
Definitions for any created fields such as age groupings, insurance status, etc.

Output/Deliverables

Describe how each deliverable should "look and feel". Specify format/layout and medium of delivery as appropriate.

Output types: Frequency table, report, data file, sum, means, Logit, other table, etc
Format: Excel, SAS, TXT, CSV, etc
Medium of delivery: SFTP, encrypted email, encrypted ZIP file, other encrypted method

Description
Deliverable 1 *
Deliverable 2
Deliverable 3
Name, Title, and Organization
Member *
Member
Member
Member
Member
Add any additional about this study here. If you have IRB approvals or patient consent, provide the details here or submit a copy with this form.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png tif txt rtf pdf doc docx pptx xls xlsx xml zip.