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QIES/iQIES Work Intake Request Form
Contact Information
Federal Contact First Name:
Federal Contact Last Name:
Federal Contact Email:
Point of Contact Email (if different from Requestor)
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Title of Intake Request:
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Request Type:
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New Feature or Business Process
Change to Existing Feature or Process
Data Extract
Ad Hoc Report
Data Research
Other
Enter other request type
System(s) Impacted:
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QIES/ASPEN
iQIES
Both QIES/ASPEN and iQIES
Impacted Program/Provider Type(s):
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Intake Request Description:
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About text formats
Attachment(s):
Unlimited number of files can be uploaded to this field.
200 MB limit.
Allowed types: gif jpg png pdf doc docx ppt pptx xls xlsx xml.
Reason for Intake Request:
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Legislative Mandate
CMS Policy Change
Other
Enter other reason for Intake Request
Is this a funded request?
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Yes
No
Not sure
Estimated Implementation Date:
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Priority:
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Critical/Must Have
High/Should Have
Medium/Could Have
Low
Justification:
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