OHCS On-line secure order form



Here's how to order
1.	Select the items that you wish to purchase.
	Check the boxes next to the items you wish to purchase. You can click on the item name to see a picture of the product. You will have a chance to preview your order summary before it is finally processed.

Data Items	Description		Price
Ambulatory Data File I	2006 Ambulatory Data File I (1996-2005 also available)	$	3150.00
Ambulatory Data File III	2006 Ambulatory Data File III (1996-2005 also available)	$	1050.00
ED Data File I	2006 ED Data File I (1996-2005 also available)	$	3150.00
ED Data File III	2006 ED Data File III (1996-2005 also available)	$	1050.00
Inpatient File I	2006 Inpatient Data File I (1992-2005 also available)	$	3150.00
Inpatient File III	2006 Inpatient Data File III (1992-2005 also available)	$	1050.00
Research Oriented Data Set	Research Oriented Data Set (HCS approval required)	$	3150.00

Confidentiality and Use Agreement

Please download the Data User Agreement ( Word or PDF format ) and return to the Office of Health Care Statistics, Utah Department of Health. Reciept of the agreement is required before any order will be sent out.

The data collected by the Health Data Committee may be used only for the purpose of health statistical reporting and analysis or specified in the user's written request for the data; any effort to determine the identity of any reported cases is prohibited. No one will attempt to link this data set with individually identifiable records from any other data sets.

User shall not redistribute the Utah Hospital Inpatient Discharge Data File in its original format. User shall not redistribute any data products derived from the file without written permission from the Office of Health Care Statistics, Utah Department of Health.

3.	I agree

Shipping and Billing Information
2.	What is the shipping destination ?
	Your purchases will be sent to the following person and location.


Name
Address
City		State
Country		Postal Code


3.	Billing information.
	Please enter your customer information, including phone number and email address in case we need to clarify your order information. If the same as shipping destination, then just fill in Phone and Email.


Name
Address
City		State
Country		Postal Code
Phone		Fax
Email


4.	Special instructions and additional information.
	If you would like data sets from previous years please check the data set you want above and specify the data year here.


5.	Proceed to the next screen to Select Quantities.
	When you click the "Select Quantities" button your chosen items will be listed and you can select quantities of each item if you want. Nothing is processed or billed until you preview your invoice. The buttons on this page do not process any billing.

Merchant OrderForm v1.4 written and produced by RGA