Appointment Report Request

Request Type:

New Report

Revision to Report

Note: Only authorized personal may request reports. If you are unsure, please email
[email protected] to see if you qualify.

Requested by (name):

Key Contact (name):

Department:

Phone Number:

System the report is to be run from:

Date needed*:

MM slash DD slash YYYY

*Note: Reports generally take 5-7 business days to process and be built. We will try our best to
accommodate the date provided.

Please provide the intent of the report:

Please provide what is expected from the report (Please explain thoroughly. This allows us to better understand what is being requested):

What fields needed on the report?

Patient information/visit:

Patient ID

Patient last name

Patient first name

Patient DOB

Patient age

Patient sex

Appointment scheduling provider

Rendering Provider

Service department

Appointment type

Appointment date

Diagnosis code

Procedure codes

Procedure codes with description

Appointment Insurance Package Name

Appointment Insurance Package ID

Other fields if not listed above or if more space is needed:

For any report requiring Diagnosis (ICD10) or Procedure Codes (CPT) to be pulled, codes MUST be provided prior to E.H.R. running the report

Date range for data (i.e. previous month, year to date, last 2 years, etc.)

How often does the report need to be run?

Once

Weekly

Monthly

Quarterly

Yearly

If not one time, specify when report is to be run (i.e. first Monday or last day of the month):

If this report is going to an Athena report inbox, please list who is to receive the report (first and last name):

EHR Team Only

Received on:

Assigned to:

Date

MM slash DD slash YYYY

EHR Approval:

Submitter(Required)

Please enter your name

QA by: