Services Request Form

Please provide the following contact information:

NAME  
TITLE  
ORGANIZATION  
WORK PHONE  
FAX  
EMAIL  
WEB ADDRESS  
Remote Coding Services   Cancer Registry Temporary Services
Onsite Temporary Coding   Data Collection and Abstraction
Coding Outsourcing   HIM Operational Review
Coding Compliance/Data Quality Review   Interim Management
Coding Education   Master Patient Index Projects
Cancer Registry Outsourcing   Trauma Registry Temporary Services
Radiology Coding   Radiology Physician Liaison
Estimated Number of Staff Needed  

Duration of Project (days and weeks)

  
Target Start Date (mm/dd/yy)  
Project Completion Date (mm/dd/yy)  


 

 

<< Back Home >>

1777 Reisterstown Road  • Suite 330  •  Baltimore, MD 21208  |  PHONE: 800.329.0365  •  410.653.0194  |  FAX: 410.653.9969