DOBI ICD-10 Implementation Task Force Consolidated Survey

Dear New Jersey Healthcare Trading Partner,

The purpose of this survey is to give your healthcare trading partners a sense of your organization’s progress in the ICD-10 transition. Our hope is that this standardized survey will give your trading partners an idea of who they need to contact in your organization to coordinate testing activities and to see when your organization will be ready to begin the testing with outside partners. Once the testing process begins between two trading partners, they will need to share information directly. No survey will be issued related to the information required between two trading partners for the purposes of their specific testing activities.

This survey will be issued and possibly updated on a regular basis since ICD-10 readiness progress will change between now and the October 2014 deadline.

By responding to this survey you are agreeing to make this information available to other New Jersey Healthcare Trading Partners that have also responded to this survey.

Please submit all your responses by March 21, 2014.

Question Title

* 1. Organization & Contact Information

Organization Name:

Street Address 1:

Street Address 2:

City:

State:

Zip:

Question Title

* 2. Organization NPI (if applicable):

Please identify and provide the contact point person that your trading partners should contact to coordinate all ICD-10 testing activities:

Question Title

* 3. Organization's ICD-10 Project Leader

First Name:

Last Name:

Phone Number:

Email Address:

Question Title

* 4. Other information you think is important for your trading partners to know about your organization and approach to organizing ICD-10 testing activities with external trading partners:

Question Title

* 5. Please select the category that best describes your organization. Your selection will determine the appropriate survey questions:

Hospital

Long Term Care Institution

Physician Practice

Outpatient Clinic

Health Insurance Carrier/Payer