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Office of Medicaid Innovation Data Request
Office of Medicaid Innovation Data Request
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Used to submit a data request to the Office of Medicaid Innovation (OMI) Data Team.
Title
A short description to explain the nature of a ticket.
Will this be a recurring request?
No
Yes
Frequency
Do you want the raw (line by line) data, or do you want the data aggregated?
Do you want the raw (line by line) data, or do you want the data aggregated?
Raw (line by line)
Aggregate
How do you want the data aggregated?
Does your data request contain PHI?
No
Yes
What data are you requesting?
What are the criteria you would like used for this data pull (i.e. date range, specific CPT codes)?
What is the purpose of this data (i.e. what is the context for this request)?
What specific fields are you wanting in the output?
Which organization(s) owns the source data?
HFS
OMI
University of Illinois
Other (Please Specify)
Clear
Other organization:
Is this request part of a larger project?
No
Yes
What was the project?
Have you requested a similar data pull before?
No
Yes
What was the previous request?
When is this data needed by?
(mm/dd/yyyy)
Who does this data need to be sent to?
HFS
OMI
Other HFS Partner (Please Specify)
Please specify who the data will be sent to:
Preferred contact email if different from submitter
Additional contacts to be included in communication
Be sure to upload completed Exhibit E below
Attachment
File attachments associated with the ticket.
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Other Fields
Your name
Your first name
Your last name
Your email address
Your phone number
Verification Code