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Data Expansion Hospital Authorization Form
Hospital Licensee:
Facililty NPI:
Licensee Agrees:
Hereby specifically agrees to submit, to the Illinois Hospital Association via COMPdata, its swing bed and all outpatient data as specified in the COMPdata Data Coordinator Manual, for the specific purpose of creating a database to facilitate research, public health, and health care operations.
Please choose all that apply:
Hospital Swing Bed IP Bill Types Accepted: 180,181
OP Bill Types Accepted: 71x,72x,74x,75x,76x,77x,78x,79x,84x,89x(Ending didgets of 0,1,2,3,4)
Swing Bed NPI:
Please provide your Swing Bed NPI if applicable, in order to process data correctly.
Begining Discharge Date:
Note: Beginning with a current open quarter and forward.
Contacts Full Name:
Phone Number:
email address: