Integration Request Form
Let's gather some information to help us best assist you.
Let us know if you're a new or returning client.
*
New client
Returning client
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Contact Information
Requester Information
Please provide us your name and best methods with which to contact you.
Company Title
*
Please provide the name of your company.
Name
*
First Name
Last Name
Title
*
Please provide your job title.
Email
*
example@example.com
Preferred Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have additional team members you would like us to include during the initial intake process?
*
I will be the main point of contact during intake.
Please add an additional team member to our correspondence.
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Team Information
Please provide your team's basic contact information.
How many recipients should we add?
*
Enter a number up to 3.
Recipient # 1: Name
*
First Name
Last Name
Recipient # 1: Title
Job title
Recipient # 1: Email
*
example@example.com
Recipient # 2: Name
*
First Name
Last Name
Recipient # 2: Title
Job title
Recipient # 2: Email
*
example@example.com
Recipient # 3: Name
*
First Name
Last Name
Recipient # 3: Title
Job title
Recipient # 3: Email
*
example@example.com
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External Organization Information
Please provide client's basic contact information where applicable.
Are you integrating with an external organization?
*
Yes
No
Other
Organization Name
*
Name of your client's practice.
Who will be the point of contact for the organization?
*
I will be the point of contact for the organization.
A representative from the organization will be the point of contact for the organization.
Organization Contact Name
*
First Name
Last Name
Organization Contact Title
Please provide your job title.
Organization Contact Email
*
example@example.com
Organization Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Vendor Information
Please provide the vendor's basic contact information.
Name of Vendor
*
Please enter the name of the software associated with this project.
Vendor Type
*
Analytic Software (or similar)
Billing Software or RCM
Electronical Medical Record (or similar)
Health Information Exchange
Instrument (lab analyzer)
Laboratory Information Systems (or similar)
Patient Portals
Practice Management Software
State Reporting
Other
Who will be the point of contact for the vendor?
*
I will be the point of contact for the vendor.
A representative from the vendor will be a point of contact for the project.
Vendor Contact Name
*
First Name
Last Name
Vendor Contact Email
*
example@example.com
Vendor Contact Phone Number
Please enter a valid phone number, if available.
Format: (000) 000-0000.
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Statement of Work
Please provide a summary of the work being requested.
Start Date
-
Month
-
Day
Year
Select a date. All parties will be engaged on this selected date.
Completion Date
*
-
Month
-
Day
Year
Select a date. The project will be considered live on this date.
Summary of Request
Brief summary of work to be performed.
Preferred Connectivity Method
*
API
Local or network folder (or similar, i.e. SMB)
SFTP (either client or vendor hosted)
TCP/IP
Undetermined
Other
If you selected "Other", please provide more information.
Enter text.
Integration Direction
*
Bidirectional
Unidirectional
Host/Query (Instrument only)
Unidirectional Only: How will the data flow?
*
Data will flow inbound into my software.
Data will flow outbound from my software.
Data will flow from
Software A
*
to
Software B
*
.
Inbound Data Type
*
ASTM
CSV or Delimited
FHIR
Flat File/Plain Text (or similar)
HL7
JSON
XML
Not Sure
Other
If you selected "Other", please provide more information.
Enter text.
Outbound Data Type
*
ASTM
CSV or Delimited
FHIR
Flat File/Plain Text (or similar)
HL7
JSON
XML
Not Sure
Other
If you selected "Other", please provide more information.
Enter text.
Inbound HL7 Data Type (MSH-9.1)
ADT
ORM
ORU
DFT
SIU
Other
If you selected "Other", please provide more information.
Enter text.
Outbound HL7 Data Type (MSH-9.1)
ADT
ORM
ORU
DFT
SIU
Other
If you selected "Other", please provide more information.
Enter text.
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Additional Information
Specifications and Sample Messages
Specifications and sample messages help us evaluate the scope of work associated with your project. Please provide any specifications or sample messages here. PLEASE OMIT ANY PHI (Protected Health Information) FROM SAMPLE MESSAGES.
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