Language
English (US)
Health New England ICD-10 Testing Form Request
Instructions:
Please fill out all required fields of this form and click complete.
ICD-10 testing contact name
*
First Name
Last Name
Your e-mail address
*
Phone number
*
Name of the entity that will be testing?
*
Type of entity represented?
*
Hospital
Provider(s) or Provider Group
Vendor
Other
Are you a direct submitter:
Yes
No
Or, if you use a clearinghouse, please indicate what type of clearinghouse you are:
Facility/Inpatient Claims
Professional Claims
Please state clearinghouse facility/inpatient name:
Please state clearinghouse professional name:
Requested testing start date (please enter in numeric format).
*
Submit
Should be Empty: