GE Healthcare


Custom Report Request Order Form
* Indicates required field   Contact Information  
*Organization name:
*Account number or short name:
*Your name:
*Phone number:
*Email address:
*Please indicate if you are a direct customer or VAR customer:   Direct Customer VAR Customer  
*Payment method:    
*Centricity product and version:
(Please go to Help, About Centricity Practice Solution or Centricity EMR, and enter the exact version and build for which this report is to be built. PLEASE NOTE: We are unable to fulfill any requests for custom modifications to Meaningful Use Reports or the MU Activity Log.
*Report type:    
Please separate each by a comma.

Once we've received your request and responded via email, you will be required to submit a draft. You have two options for submitting a draft:

  1. Print a report from CPS/CEMR that closely resembles the report you need. Write in the changes, being as specific as possible regarding headings, groupings, how the data should pull, etc. Scan your draft and email your draft to
  2. Create a draft in MS Word or MS Excel with the details and fields needed, being as specific as possible as to headings, groupings, how the data should pull, etc. Make sure that you use the exact CPS/CEMR fields as they are named in the software. Email your draft to
Please click Submit to complete the Custom Report Request.  
* Indicates required field