"Hospital Inpatient / Emergency Department Discharge Data Request Form" - Connecticut

Hospital Inpatient / Emergency Department Discharge Data Request Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on August 14, 2008;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Hospital Inpatient / Emergency Department Discharge Data Request Form" - Connecticut

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Record/Invoice Number: ____________
STATE OF CONNECTICUT
Office of Health Care Access
Freedom of Information
Hospital Inpatient / Emergency Department Discharge Data Request Form
Date: _____________
The Office of Health Care Access (OHCA) maintains an acute care hospital inpatient discharge database, has
access to ChimeData emergency department database and fills requests for aggregate health data from all
interested individuals, institutions and other government agencies.
Data released to interested parties
however are subject to the provisions of section 19a-167g-94 of OHCA’s Budget Review Regulations and the
Health Insurance Portability and Accountability Act (HIPAA) of 1996 and other local, state and federal
regulations relating to the maintenance of patient privacy.
Fees may be associated with responding to these requests. Only request forms that are fully completed will be
considered. Discharge categories with fewer that six patients will be noted as less than six (<6).
For more information, contact OHCA at (860) 418-7001 or ohca@ct.gov,
After submitting your request, you will be notified within four (4) business days whether: 1) the request has
been approved for preparation, 2) the request has been denied because it involves confidential information or
does not meet required thresholds, or 3) it cannot be readily determined until the report is prepared whether or
not it meets required thresholds.
Please review Section 19a-167g-94 of OHCA’s regulations (especially section (g) on pages 87-92) for an
overview of the data request process, data elements collected, confidential data elements, and required
thresholds before completing this request form.
INFORMATION REQUESTED – (PLEASE FILL OUT ALL INFORMATION AND ATTACH ADDITIONAL
PAGES IF MORE SPACE IS REQUIRED)
1. LIST OF DATA ELEMENTS TO BE INCLUDED:
2. DATA SELECTION CRITERIA (e.g., specific ICD-9-CM codes, DRG codes, demographic
variables, or at least two contiguous zip codes, if zip code information is being requested):
st
3. TIME PERIOD FOR REQUESTED DATA (Fiscal years available: Inpatient 1991– 1
6 months 2012,
Emergency Department 1996-2010)
Record/Invoice Number: ____________
STATE OF CONNECTICUT
Office of Health Care Access
Freedom of Information
Hospital Inpatient / Emergency Department Discharge Data Request Form
Date: _____________
The Office of Health Care Access (OHCA) maintains an acute care hospital inpatient discharge database, has
access to ChimeData emergency department database and fills requests for aggregate health data from all
interested individuals, institutions and other government agencies.
Data released to interested parties
however are subject to the provisions of section 19a-167g-94 of OHCA’s Budget Review Regulations and the
Health Insurance Portability and Accountability Act (HIPAA) of 1996 and other local, state and federal
regulations relating to the maintenance of patient privacy.
Fees may be associated with responding to these requests. Only request forms that are fully completed will be
considered. Discharge categories with fewer that six patients will be noted as less than six (<6).
For more information, contact OHCA at (860) 418-7001 or ohca@ct.gov,
After submitting your request, you will be notified within four (4) business days whether: 1) the request has
been approved for preparation, 2) the request has been denied because it involves confidential information or
does not meet required thresholds, or 3) it cannot be readily determined until the report is prepared whether or
not it meets required thresholds.
Please review Section 19a-167g-94 of OHCA’s regulations (especially section (g) on pages 87-92) for an
overview of the data request process, data elements collected, confidential data elements, and required
thresholds before completing this request form.
INFORMATION REQUESTED – (PLEASE FILL OUT ALL INFORMATION AND ATTACH ADDITIONAL
PAGES IF MORE SPACE IS REQUIRED)
1. LIST OF DATA ELEMENTS TO BE INCLUDED:
2. DATA SELECTION CRITERIA (e.g., specific ICD-9-CM codes, DRG codes, demographic
variables, or at least two contiguous zip codes, if zip code information is being requested):
st
3. TIME PERIOD FOR REQUESTED DATA (Fiscal years available: Inpatient 1991– 1
6 months 2012,
Emergency Department 1996-2010)
4. SAMPLE REPORT LAYOUT (Must be attached):
SELECT TYPE OF MEDIA AND FORMAT FOR REPORT:
5. MEDIA
E-mail
Paper Report
CD-ROM
Format
MS EXCEL (.xls)
ASCII (.txt)
6. Return Request by: (Please check one)
E-mail
Fax
Pick Up
Mail
Submission of this form serves as confirmation that the request conforms to the confidentiality provisions
of Office of Health Care Access regulations.
Requestor Information:
____________________________________________________________________________________________________________
Name
____________________________________________________________________________________________________________
Company
____________________________________________________________________________________________________________
Street Address
____________________________________________________________________________________________________________
Town, State and Zip Code
____________________________________________________________________________________________________________
Telephone and Fax Number
____________________________________________________________________________________________________________
Email Address
Your bill for this service is:
Files on CD @ $5.00 per file
$
Paper Copies @ $.25/page
$
Programming and formatting fee @ $9.39/quarter hour
$
Postage & Shipping Charges (if applicable)
$
Total Amount Due
$
Payment: PLEASE MAKE CHECKS PAYABLE TO “TREASURER, STATE OF CONNECTICUT” AND
REMIT TO THE OFFICE OF HEALTH CARE ACCESS. 410 CAPITOL AVENUE, MS#13HCA, P.O.BOX
340308, HARTFORD, CT 06134 AS SOON AS POSSIBLE. PLEASE BE SURE TO INCLUDE ONE
COPY OF THIS BILL WITH YOUR PAYMENT.
Revised August 14, 2008
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