EHR Data Request Form

HSRDC provides a secure, user-friendly computing platform for health research, enabling remote collaboration and data analysis entirely on its servers via virtual desktops.
A short description to explain the nature of a ticket.
Please briefly describe your data request, include any inclusion or exclusion parameters. Example domains of data include the following:
  • Demographics (e.g., age, sex, race, ethnicity) 
  • Clinical Diagnoses (e.g., ICD-10 codes, problem list entries)
  • Medications (e.g., drug name, RxNorm codes, prescription dates)
  • Lab Results (e.g., test name, LOINC codes, result values, units)
  • Procedures (e.g., CPT codes, procedure dates)
  • Encounters (e.g., visit type, location, admission/discharge dates) 
  • Vitals (e.g., blood pressure, height, weight)
  • Other (e.g., provider speciality, insurance type, social determinants)
The full details of a ticket, including any appropriate circumstances or supplementary information that may aid in resolving it.
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Check each of the following options that apply to your requested data extract
Check each of the following options that apply to your requested data extract (required)
File attachments associated with the ticket.
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Filling out the relevant supplementary form will help our team better support your request, but it is not required
What type of clinical data are you requesting?
What type of clinical data are you requesting?
What types of IDs do you plan to provide?
What types of IDs do you plan to provide?

Other Fields

Your name
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