Laboratory Information System Connectivity Request Form
Submit this form to request and configure connectivity between a laboratory information system and another system. Please provide detailed and accurate information to ensure a smooth integration process.
Requester Full Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Requester Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Name
*
Department
LIS System Name
*
External System Name
*
Role of LIS in Integration
*
Sender
Receiver
Both Sender and Receiver
Role of External System in Integration
*
Sender
Receiver
Both Sender and Receiver
Request Type
*
New Connectivity Request
Modification to Existing Connection
Troubleshooting/Issue Resolution
Other
Preferred Connectivity Method/Interface
*
Please Select
HL7 (Health Level Seven)
ASTM
REST API
SOAP Web Service
File Transfer (SFTP/FTP)
Other
Target Environment
*
Test
Production
Both Test and Production
Data Exchange Needs (Select all that apply)
*
Patient Demographics
Order Entry (e.g., Lab Orders)
Results Reporting
Specimen Tracking
Billing Information
Other
Message Standard or File Format
*
Please Select
HL7 v2.x
HL7 v3
FHIR
ASTM
CSV
XML
JSON
Other
Data Exchange Frequency/Timing
*
Real-Time
Hourly
Daily
On Demand
Other
Required Go-Live Date or Timeline
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Technical Support/Contact Details
Additional Technical Notes or Requirements
Submit Request
Should be Empty: