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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
All expanded outpatient data including diagnostics, labs, rehab, oncology, mental health, dialysis, and any other service provided on an outpatient basis. OP Bill Types also accepted: 71x,72x,74x,75x,76x,77x,78x,79x,84x,89x (Ending digits of 0,1,2,3,4)
Swing Bed NPI:
Please provide your Swing Bed NPI, if applicable, in order to process data correctly.
Beginning Discharge Date:
Note: Beginning with a current open quarter and forward.
Contact Full Name:
Phone Number:
Email Address: