QI Data Request Form - Henry J. Austin Health Center

The form will take approximately 5 minutes to complete. The questions marked with an asterisk are mandatory.

Your Email(Required)

Today's Date(Required)

If you selected 'Program' in the previous question, please specify name of the program below

Date when report is needed(Required)

(please allow a minimum of 3 business days)

Please provide a brief written description of the report being requested. Use this space to provide as much detail as possible

Example : Cervical Cancer Compliance. Report of non-compliant PAP Smear Patients with visits scheduled with in following 4 wk time frame.

Please provide a list of data items to be included in the report(Required)

Example: Patient Name, DOB, Age, Chart #, Facility, Provider, Primary Insurance, Appt Date

11. Any additional information that you would like to provide

Attach files or previous sample reports here

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.