PLACE YOUR ORDER

Please complete the following order form. This information is held in strict confidence. We do not share the information we gather from this form with any third party. DataCodes will only use this information to send you a bill for the data, or to provide you with information regarding your order, or to notify you of updates to the code sets.

Once you have completed and submitted this form, we will validate your order. You will be invoiced by DataCodes (by email and by US mail). If you are one of Eldorado's ASP clients, we will notify Eldorado's HEALTHware Administrator to coordinate the installation of your updates. Otherwise, we will provide you the information necessary to download the appropriate codes to update your system.

YOUR NAME:
YOUR TITLE:
COMPANY:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
Direct Billing Invoice To the Attention of:
Your Purchase Order Ref # (if any):
YOUR EMAIL:

Number of Users (see instructions at the left margin):

medical

dental

Order 2004 HCPCS Codes (does not include CPT4 codes)
layout		1-19 users	20+ users
		$179.95	$279.95
Order 2004 ICD9 Codes
layout		1-19 users	20+ users
	ICD9-Vol 1 diagnosis:	$179.95	$279.95
	ICD9-Vol 3 procedure:	$ 65.00	$ 89.95

Order 2004 CPT-4 Codes
layout	1-10 users	11-19 users	20+ users
	$175.00	$265.00	$ 75 +$ 10 per user
Order 2004 CDT-4 Dental Codes
layout	1-10 users	11-19 users	20+ users
	$175.00	$265.00	$ 75 +$ 10 per user

Additional comments or information:
	SUBMIT     CLEAR FORM