Schedule Em-C - Electronic Medical Records Credit - Certification - 2012
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1Schedule
EM-C
Electronic Medical Records
Credit - Certification
Wisconsin Department
2012
Due Date: January 31, 2013
of Revenue
A. Business Information
Check (ü) if this is an AMENDED return.
Entity Legal Name (if applicable)
Federal Employer ID Number
Legal Last Name
Legal First Name
M.I.
Social Security Number
Number and Street
Suite Number
City
State
Zip Code
Contact Person
Position
Phone Number
E-mail
For Parts B & C: Calendar year filers – Fill in purchases from January 1, 2012 thru December 31, 2012.
Fiscal year filers – Fill in purchases from your fiscal year beginning in 2012 thru December 31, 2012.
B.
Qualified Medical Record Software Purchased
Product Name
CHPL Product Number
Amount Paid
1
1
1
.00
2
2
2
.00
3
3
3
.00
.00
4
4
4
5
5
5
.00
.00
6
6
6
7
7
7
.00
.00
8 Total additional purchases reported on attached schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Total qualified medical record software purchases (add lines B1 through B8) . . . . . . . . . . . . . . . . 9
.00
C.
Qualified Medical Record Hardware Purchased
Product Category
Amount Paid
.00
1 Servers:
1
2 Computers/Notebooks:
2
.00
.00
3 Printers:
3
4 Other:
4
.00
5 Total qualified medical record hardware purchases (add lines C1 through C4) . . . . . . . . . . . . . . . 5
.00
D.
Signature
I hereby certify that to the best of my knowledge and belief the above-listed purchases are for information technology
software certified by the Office of the National Coordinator for Health Information Technology and hardware used to
run or access certified software.
Print Name
Signature (unless submitted electronically)
Date
If you are not filing this schedule electronically, mail it to:
Wisconsin Department of Revenue
Electronic Medical Records Credit
PO Box 8932
Madison WI 53708-8932
IC-072CRT
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