HIT Technical Assistance Request Survey

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Please provide the following demographic information

Please provide the following demographic information Name:
State:
Country:
Email Address:
Phone Number:

Please select which of the following best describes you:

Please select which of the following best describes you: Pediatrician

Non-pediatric physician

Office Staff

Child Advocate

Health Care Professional

Medical

National Organization

AAP State Chapter Leadership

Resident

State Agency

State Team

Other

Please select the topic area that best describes your need for technical assistance

Please select the topic area that best describes your need for technical assistance Electronic Health Record Adoption & Implementation Meaningful Use Standards & Certification Meaningful Use Incentives HIPAA Rules National Provider Identifier	AAP Meeting Representation Request Regional Extension Centers Patient Portals Health Information Exchange
Other (please specify)

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Please describe your technical assistance request

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