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00054 <br />Page 4 of 4 <br />Attachment A <br />Activity 113 Electronic Health Record Report for FY 17 <br />Local Health Department <br />(specify county if this is a <br />district health department): <br />Attachment A is for FY 17, which is for the Service Period of October 1, 2016 — May 31, 2017. <br />Complete Attachment A and return between June 1-30, 2017. <br />I. Complete the following grid indicating how funds were utilized. <br />Deliverables <br />Dates of service <br />Vendors <br />Amount expended <br />(Activity 113 <br />Financial support for the purchase of Centers <br />for Medicare and Medicaid Services (CMS) <br />certified electronic health record <br />Financial support for subscription services <br />associated with ePrescribing <br />Financial support for customization of an <br />electronic health record to accommodate batch <br />reporting to HIS <br />Financial support for purchase of imaging <br />solutions to work in conjunction with an <br />electronic health record <br />II. Attach a copy of the approved Electronic Records and Imaging Policy <br />(Template available from Kurt Brenneman, Records Management Analyst, Government Records <br />Section/Division of Archives and Records, N.C. Department of Natural and Cultural Resources <br />4615 Mail Service Center, Raleigh, NC 27699-4615, (919) 807-7357) <br />III. Attach a copy of the approved Electronic Medical Records policy specific to the purchased EHR software <br />Return to Beth Murray by June 30, 2017 either by email, fax, or mail. <br />Email: beth.murray@dhhs.nc.gov <br />Fax: 919-870-4833 <br />Mail: 1916 Mail Service Center, Raleigh, NC 27699-1916 <br />Effective July 2015 <br />