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Name/Title:
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Organization:
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Address:
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City, State, Zip:
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Telephone: |
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Fax: |
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Email: |
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1. Please describe the type of organization which you
represent. |
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2.
Please describe, in
detail, how the requested information will be used.
(e.g. market share study) |
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3. Please identify to whom the requested information
and/or results of analyses of the information will
be redistributed.* (e.g. to support certificate of
need)
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*PLEASE NOTE: The parameters specified below will be
included as limitations on data usage and redistribution
to which your organization must agree to adhere in
accepting the terms of any subsequent Chime information
request contract that is prepared |
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Please Tell Us: |
Define Details: |
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Fiscal Year or Calendar Year:
(check one) |
Calendar Year
Fiscal Year |
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List Years Requested:
(Select all that apply)
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Type of Patient: (Select all that apply) |
Inpatient (excluding newborn)
Inpatient (including newborn)
Newborn (displayed separately from inpatient)
Outpatient Surgical
Emergency Department NonAdmission |
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DRG Version. If requesting multiple years, would you
like the most current DRG version applied to all fiscal
years selected? |
Yes
No
Comments:
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Will the data be aggregated or case level? |
Aggregated
Case Level |
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Data Format: (up to 2 formats may be selected) |
Report format (snapshot w/viewer)
Comma delimited data file
Excel data file
Access database
Fixed length data file
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Output media (select one) |
CD Rom
Diskette |
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Enter Date data needed by: |
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Some data requests may be fulfilled from our Comparative
Report series. Chime staff will advise the best way to
access the information. Depending upon the data elements
needed, prepackaged Comparative Reports may be available
to the requester. |
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If requesting market share study, e-mail a selected list
of town or zip code names to
the ChimeData Help Desk at
chime.data@chime.org, or (203) 294-7333. |
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PLEASE NOTE: Release of certain data fields,
particularly in non-aggregated formats, may be
restricted to protect patient and provider
confidentiality. |
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Data Elements (Please check all elements desired): |
(Ctrl/Left Click will allow multiple selections to be
made)
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