Submit a request – Patient Access Data Requests

Your email address

Zendesk Change Request Type

Approver Request Type

Please select the requested change:(optional)

Please describe desired automation functionality.(optional)

Descriptions should include conditions, such as: Send an email if an approval has not been approved in 24 hours.

Specialty Name

Please enter all affected locations for this request:(optional)

Select request types that should be included for approval:(optional)

Zendesk Change Request: If your request type is Other or is not shown above please type it here:(optional)

Zendesk Change Request: If your request type is Other or is not shown above please type it here:

Zendesk Change Request: Please select the date you would like this change to start.

Zendesk Approver Request - Please select the End Date for the temporary approver to be notified

Start Date for Modality Approval Bypass(optional)

when should we start bypassing modality approval

End Date for Modality Approval Bypass(optional)

when should we start approvals back up for the modality

Zendesk Change Request: Please provide the Provider's Name (format: Last Name, First Name) as displayed in Epic:

Please provide the Provider's SER ID as displayed in Epic:

Zendesk Change Request: Please provide the Provider's Department Name and Department ID as displayed in Epic:

Zendesk Change Request: As this request is for multiple providers, please include the Provider Name(s), SER ID(s), Department Name(s) and Department ID(s) in the description box below.

Please provide additional details for the requested information here:(optional)

i.e. provide approvers for cardiology template requests at EUH

Select Modality Approver

The approver that will not be available during the specified timeframe.

Approver Levels to Add/Update(optional)

Please enter the new primary approver's name.(optional)

Please enter the new secondary approver's name.(optional)

Agent Change Type(optional)

Enter Current Supervisor Name(optional)

(If this is a transfer, please provide the Supervisor name that the agent is transferring FROM)

Enter Agent Name(optional)

Enter Agent ID (UKG)(optional)

Please enter new supervisor name(optional)

If you are submitting a request to add a location and/or a provider, please be aware that all JSON updates are made on Wednesday and Friday afternoon.

Zendesk Change Request: Is this issue preventing the immediate care or scheduling of a patient?(optional)

Zendesk Change Request: Is this issue preventing the immediate care or scheduling of a patient?

Please provide a name for the new macro(optional)

Please provide the macro name that needs to be edited(optional)

Please select the macro share option(optional)

this will indicate who should have access to the macro

Please provide the agent group or groups that should have access to the macro(optional)

Select Desired Macro Behaviors

if unknown, provide description

Provide description of workflow the macro will be used for(optional)

Provide description of the edit needed for macro(optional)

User First Name(optional)

User Last Name(optional)

User Preferred Display Name(optional)

New User Email Address(optional)

New User Role Type(optional)

Zendesk user type

Please provide a brief description of your request.

PLEASE DO NOT INCLUDE ANY PATIENT HEALTH INFORMATION! Please provide a detailed description of the schedule change you are requesting or place an attachment in the field below. Include location, date(s), time(s), and appointment type(s). Please do not include Patient Names, MRN and other patient information.

Attachments(optional)

Add file or drop files here