Contact Name:
Title:
Hospital Name:
Hospital Address:
City:
St:
Zip:
Phone:
Fax:
E-mail:
(required)
1. Annual number of discharges
2. ALOS
3. Percentage of discharges
Medicare
Other Payers
Medicaid
4. Specialty departments (to identify case mix)
Cardiac Surgery
Trauma Center
NeoNatal ICU
Psych Unit
Burn Unit
5. Abstracting Required?
YES
*
NO
*
If yes, please fill in abstracting guidelines
6. Data Entry Required:
YES
*
NO
*
If yes, please fill in entry guidelines
and type of system used
7. # FTE Coders
8. Usual Daily Productivity
Include any comments or questions here:
