Provider Data Request FormAre you a healthcare provider and another provider is treating your patients whose records you’d like to access? Fill in this form and we’ll work to gather the necessary information on your behalf! Your Organization's Name * Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Which Northern Nevada hospitals would you like to receive data from? * All Northern Nevada Hospitals Banner Health Carson Tahoe Mt. Grant Hospital Northeastern Nevada Regional Northern Nevada Medical Center Pershing General* Reno Behavioral* Renown Regional South Lyon Hospital* St Mary's Regional Tahoe Pacific William Bee Ririe Willow Springs* Which Southern Nevada hospitals would you like to receive data from? All Southern Nevada Hospitals Dignity Health Elite Medical Center* Encompass Grover C. Dils Medical Center Horizon Specialty Hospitals* Kindred Hospitals* Las Vegas AMG Hospital* Mesa View Regional* Mountain View Hospital* North Vista Hospital* PAM Rehabilitation Hospital* Seven Hills Behavioral* Southern Hills Hospital* Sunrise Hospital* University Medical Center Valley Health Specialty Hospital* Valley Health System What Diagnostic Imaging and Laboratory Providers would you like to receive data from? Desert Radiology / Radiology Partners Steinberg Diagnostic Medical Imaging Pueblo Medical Imaging Reno Diagnostic Centers Clinical Pathology Laboratories LabCorp Laboratory Medical Consultants Pathology Services Quest Diagnostics What other healthcare organizations would you like to share data with or receive data from? By typing your name and clicking Submit below you are acknowledging the following: * Pursuant to the 21st Century Cures Act Information Blocking provisions (45 CFR 170 and 171) I am formally requesting that the organizations I have identified below comply with this federal rule and send their data to the HealtHIE Nevada HIE so that it can be added to my existing interfaces for my patient/member population. I am not seeking additional point to point interfaces with these organizations as this would incur costs for my organization, and in effect would constitute a business practice that would limit information sharing. Thank you! We’ll work to gather the necessary information on your behalf. Please let other providers know about this form as well.
