Appointment Report Request
Request Type:
New Report
Revision to Report
Revision to Report
Note:
Only authorized personal may request reports. If you are unsure, please email ehrdept@mcr.health 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: