External Data Request Form

Enter a phone number in which you can be reached during business hours (Mon - Fri, 8 am - 5 pm EST).

DCH has a standing service level agreement depending on the type and complexity of request. We will do our best to complete the request by this date, however providing this date does not guarantee delivery by this date.

Select the option which best describes the audience for your data request.

Definitions: Health Care Operations - any of the following activities of the covered entity to the extent that the activities are related to covered functions. Research - systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge.

Please provide the question you intend to answer with the requested data. Providing specificity on the intended use allows us to better meet your data request needs.

Use the Start and End Dates to specify the time range of your report request.

Note: Our data may lag by six to eight weeks of the current time period.

Select the Time Increment for your report output. For example, do you want to show data in monthly or quarterly time increments. If you don't see your preferred option, select Other and provide details in the Time Increment-Other field which will be visible once you select the Other or Customer option.

Please select one or more date options for your data request. Use the Additional Comments and Criteria section to provide details on how to use multiple selected date parameters. (Select all that apply)

Please select from the list below your preferred report format. Use the Additional Comments and Criteria section to provide details on how to use multiple selected Report Format parameters. (Select all that apply) The default option is "--No Preference--." If you do no select an option, DSS will provide a Report Format best suited for your request.

• Use this field to indicate additional specifications for your data request. • Examples include listing data elements or defining population criteria. • Completion of this field is optional; however, specificity allows us to better meet your data request needs.

Please attach any documents to support your data request. Examples include previously created reports, code listings, and report templates.

• The name in the box below is the same person completing this data request form • The information requested will be used for the purpose stated in this request only • The information requested will not be used for malicious intent.