Health New England ICD-10 Testing Form Request
Please fill out all required fields of this form and click complete.
ICD-10 testing contact name
Your e-mail address
Name of the entity that will be testing?
Type of entity represented?
Provider(s) or Provider Group
Are you a direct submitter:
Or, if you use a clearinghouse, please indicate what type of clearinghouse you are:
Please state clearinghouse facility/inpatient name:
Please state clearinghouse professional name:
Requested testing start date (please enter in numeric format).
Should be Empty: