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QI Data Request Form

QI Data Request Form

HomeQI Data Request Form
The form will take approximately 5 minutes to complete. The questions marked with an asterisk are mandatory.
Your Name(Required)
MM slash DD slash YYYY
Site Location(Required)

Department(Required)

Name of the requester(Required)
(please allow a minimum of 3 business days)
MM slash DD slash YYYY
Frequency of the report
Type of report

Example : Cervical Cancer Compliance. Report of non-compliant PAP Smear Patients with visits scheduled with in following 4 wk time frame.
Example: Patient Name, DOB, Age, Chart #, Facility, Provider, Primary Insurance, Appt Date
Drop files here or
Accepted file types: doc, docx, xls, xlsx, pdf, jpg, jpeg, gif, png, webp, ppt, mov, mp4, mp3, Max. file size: 50 MB, Max. files: 8.

    Contact Us

    321 N. Warren Street
    Trenton, NJ 08618
    (609) 278 – 5900
    info@henryjaustin.org

    Pharmacy Delivery Available! (609) 278 – 5931
    Employee Portal 

    HJAHC receives HHS funding and has federal Public Health Service deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

    This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).

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    © 2022 Henry J. Austin Health Center

    We are currently closed. Actualmente estamos cerrados.

    Please contact our after-hours line to be connected to an on-call provider at 609-278-5900. If you have a medical emergency, please call 911 and go to your nearest hospital.

    Comuníquese con nuestra línea fuera del horario de atención para conectarse con un proveedor de guardia al 609-278-5900. Si tiene una emergencia médica, llame al 911 y vaya a su hospital más cercano.

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    Giving is not just about making a donation. It is about making a difference. – Kathy Calvin
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