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Data Extraction Authorization

Please complete the Data Extraction Authorization form below. The completed form will be emailed to the Subscriber, the EHR Vendor, and HealthCare Registries.

Data Extraction Authorization

I hereby authorize [EHR Vendor will be added automatically] to release my access code and proper API credentials, web interface (SOAP) and/or API interface for my practice.

I am requesting that [EHR Vendor will be added automatically] send these credentials to the HealthCare Registries, LLC to the attention of: DennisBall@HealthCareRegistries.com and copies to: RonSnyder@HealthCareRegistries.com, GabeBologea@HealthCareRegistries.com

EHR Vendor(Required)

Other EHR Vendor

EHR Vendor Primary Contact(Required)

First Last

EHR Vendor Contact's Email(Required)

Subscriber's Primary Contact(Required)

First Last

Subscriber's Email(Required)

Practice Name(Required)

Title(Required)

Date(Required)

Signature(Required)

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