Data Submission Services | COMPdata Informatics

Facility Name:	Billing Information
Facility NPI:
Attention of:
Title:
Email:
	Yes, receive a copy of the invoice by email
Billing Address:
Purchase Order :	Late Load Contact Information: The individual who is authorized to confirm final counts
Full Name:
Title:
Phone number:
Email:	Choose the appropriate Late Load quarter count. Fees are for separate or combined patient data types.
1 to 4Qtrs:	Late Load Fee: $5,000 per hospital
5+ Qtrs:	$7,500 per hospital
Agree:	I understand and agree to the removal of the existing data for the chosen time frame and agree to reload complete and accurate data. Understand that late load submission is not accepted by IDPH. Montana Hospitals requires prior written consent by MHA and may include additional fees. Late Loads are considered complete for release based upon the timeframe of the receipt of payment and confirmation of final counts to COMPdata. See instructions on late load web page and release cycle dates.
Provide each Quarter by Patient Type and Year to be removed:	example: 1QIP2022,1QOP2022(OP= outpatient Services)

Late Load Form