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Priority

Add / Remove Radiologist

Account 1 Email Address This address must be unique and cannot be used for multiple AMBRA accounts. Account 1 First Name Account 1 Last Name Account 1 Title Account 2 Email Address Optional This address must be unique and cannot be used for multiple AMBRA accounts. Account 2 First Name Optional Account 2 Last Name Optional Account 2 Title Optional Account 3 Email Address Optional This address must be unique and cannot be used for multiple AMBRA accounts. Account 3 First Name Optional Account 3 Last Name Optional Account 3 Title Optional Additional Physicians Optional Enter any additional physicians, IDs, and destinations. Address Ambra Account(s) Optional List any additional employees that will need an Ambra account. Include name, email address, position (e.g. technologist, office staff) Contact Email Address Optional Contact Phone Number Optional Destination

Select...

Destination Optional

Select...

Destination Optional

Select...

Destination Optional

Select...

Destination Optional

Select...

Gateway Type

Bidirectional

One way: Envision to Remote Site

One way: Remote Site to Envision

FOR AMBRA ACCOUNTS ONLY: Group Name Optional Ambra Issue Select the issue you are experiencing with Ambra.

Forgot password

Account is disabled

Account is locked

Images not sending

Patient Jacket not in Ambra

Report not in Ambra

Retrieve Thin Studies

Study not in Ambra

IT Contact Optional Enter the IT/PACS contact if different than the project coordinator. IT Contact Email Address Optional IT Contact Phone Number Optional Office Phone Number FOR AMBRA ACCOUNTS ONLY: Office Website Optional Other Destination Optional Other Destination Optional Other Destination Optional Other Destination Optional Other Destination Optional PACS System Optional Enter the PACS system used by the referring office if available e.g. Fuji PACS, NovaPACS, etc. PACS AET (AE Title) Optional Enter the AE Title of the remote PACS system (if applicable). AE Titles are case sensitive. PACS IP Address Optional Enter the IP Address of the remote PACS system (if applicable). PACS Port Number Optional Enter the Port Number used by the remote PACS system (if applicable). Physician ID in RIS Enter 0 [zero] if not applicable. Physician ID in RIS Enter 0 [zero] if not applicable. Physician ID in RIS Enter 0 [zero] if not applicable. Physician ID in RIS Enter 0 [zero] if not applicable. Physician ID 5 Enter 0 [zero] if not applicable. 1. Physician Name 2. Physician Name Optional 3. Physician Name Optional 4. Physician Name Optional 5. Physician Name Optional Referring Physician(s) Optional List any referring physicians that will need an Ambra account. Note that for image autorouting an account must be created. Include Name, email address, and RIS Physician ID. If requesting an account for a Referring Physician provide the RIS physician ID so routing can be configured Optional Requested By Enter the name of the requesting Envision employee. Site Contact Enter the onsite contact who will be coordinating the project. Ambra Username Optional Enter the email address associated with the Ambra account.

Application Name

Select the application you are experiencing an issue with

Bulk Check Amount Optional Call back Request Optional Yes No Select this option if you would like to be called regarding this ticket. CD Burning Device Select the device you are using to create CD/DVD.

PACSCube

PACSGear

My Computer

Change Requested Optional Explain what access you require changing from and to. Computer Name Optional Please enter your computer name if you know it. Accession Number Include the FULL accession number (e.g. ALN1234567, BLD1234567, CPFP1234567). Accession Number Optional Accession Number Optional Accession Number Optional Cubicle location/number Optional Date of Deposit Optional

Date of Service

Employee Start Date

Enter the user's start date This field is required Add CPT / Description Optional

Add CPT code

Add Exam Description

Edit Existing CPT Code / Description Optional

Edit existing CPT code

Edit existing description

Add or Edit

Add

Edit

Contact Name Contact number or email CPT Code Optional CPT Description Optional Date Sent (Exam Completed)

Exam ID EMR NPI 1 Optional NPI 2 Optional NPI 3 Optional NPI 4 Optional NPI 5 Optional NPI Number Order Placement Date Optional

EMR Orders or Results Optional Mark whether the issue is with orders or results.

Orders

Results

Date of Birth Optional Patient Name Physician ID 1 Optional Physician ID 2 Optional Physician ID 3 Optional EMR Physician ID 4 Optional Physician ID 5 Optional If more that 5 additional providers needed, please upload document / form. Optional Please leave blank. Provider Name Referring Office

Request Type

EMR System

EMR Vendor Optional

Select...

End Date

This field is required Envision Accession Number Optional e.g. TUL12345678 Escalate Optional Yes No Escalation Yes No Effective Date

From which date do you require this change to be effective? EFT/ Check Number Exam ID Optional The patient exam id / accession number ***Please submit a request to extend access*** Optional [Leave this box empty] External Fax Number Optional Enter the fax number you are trying to send to. Internal fax number Optional Enter the receiving fax number Multiple Locations Affected Optional Yes No Is this problem affecting multiple users/offices? Fax Receive Destination Optional

I cannot receive faxes in RIS

I cannot receive faxes on my fax machine or multifunction fax/printer/copier

Fax Send Destination Optional

I cannot send faxes from RIS

I cannot send faxes from my fax machine or multifunction fax/printer/copier

Have you called to verify that it is a working fax number Optional Yes No Hardware Type Optional

Select...

Hardware Type

Imaging Systems Imaging systems involved in this workflow change.

Ambra

DICOM Router (Silverback)

Film Printer

Hologic

IntelePACS

LifeImage

MIM

NeuroQuant

PAL

PowerScribe

PowerShare

ResMD

Synapse

TeraRecon

Other

Impact Optional

A workaround is available until this can be fixed

I cannot do my job until this is fixed

Insurance Company Name Insurance Paid Optional Fax: Internal Fax number Optional Enter the fax number users are trying to send a fax to. Issue Optional Please describe the issue you are experiencing. Job Title Optional Location

Select...

This field is required Center List Make changes to exam(s) for the selected centers.

ALN

ASI

BED

BLD

BRI

BWI

CLE

CRK

CSI

DES

EPL

ENV HUB

FRI

HCH

HCR

HDH

HDW

HFC

HIL

HLM

HND

HNF

HSL

HSP

HUL

HWL

KEL

LAC

LAF

LAM

LSM

MAN

MCK

NAR

NFR

OCC

OCL

OLT

PEN

PLA

SAR

SDI

SLA

SNY

SWF

TFI

TUL

TYA

TCL

WHP

WLK

WLM

WPK

WSL

WYL

Manager Optional The name of your new user's manager. Center Manager or Supervisor name This field is required Marketer Optional Enter the name of the Envision Marketer that supports this customer. Modality Type Optional

Mammo

X-Ray

All Modalities

Name Optional The first and last name of the new user. Employee Name Optional Temp Tech Name This field is required New or Replacement Modality Select this option when installing a new modality.

New Additional Modality

New Replacement Modality

Change Existing Modality

Office Address Optional Organization Contact Email Address Optional Organization Contact Name Provide the point of contact at the organization for this project. Organization Contact Phone Number Optional Organization Name Provide the official full organizational name. Do not include abbreviations or acronyms. Organization Phone Number Provide the main phone number for the organization. Include area code. Organization Website Optional Provide the website address for the organization. Other Optional If the agency is not listed in the drop down, please add agency name to this field.

Covering Radiologist

Current Radiologist

(If desired radiologist is not listed please add in the message field)

End Date

End Time Enter the time to end he reassignment. Please include AM or PM.

At End Date Set Radiologist Back To:

Select the radiologist to reassign to.

Start Date

Start Time Enter the time to start the new assignment. Please include AM or PM. FOR AMBRA ACCOUNTS ONLY Optional Please select if a new group is needed or if accounts should be added to an existing group/location.

Add accounts to existing Ambra Physician Group/Location

Create a new Ambra Physician Group for these accounts

Invite existing Ambra user to Envision/Health Images account

PACS: Existing Physician Name Enter the existing name exactly as it appears in the eRIS physician record e.g. John T Doe [REQUIRED].

Category

Patient Account Number Patient Name Please enter name in format Last Name, First Name Patient Paid Optional Payment Amount Optional Payroll Report Due Date Optional

The date you would like the report.

Payroll Request

Extension Optional Phone Number Optional Phone Number Optional Phone number for the new user. Phone number or extension you are calling from Optional Phone number or extension you are calling Optional Physician Name Optional

Position

This field is required

Practice Name Optional Procedure Code Radiologist Optional Radiologist Type Optional If adding a radiologist, select what function(s) he or she will perform.

Interpreting Radiologist

Supervising Radiologist

Reason for Request- Payments

Select...

Reason for Request- Rates

Reason for Request- Refunds

Referring Office Optional Yes No Is the problem affecting a referring office? Referring Office Information Optional Enter the name of the referring office, a contact name, and a contact number or email address. Refund Amount Requested

Region

Requested Username Optional The username of the new user account (alphanumeric only). RIS Physician ID / NPI Optional RIS Request Category Optional

Change Procedure

New Report

Step Exam Back

Other

Scheduled Vendor Support Optional Enter date & time your vendor will be onsite for troubleshooting. Series or Image details Optional Provide the date & timestamp of the series and/or images. SERIES: Provide the EXACT series description as it appears in PACS. IMAGES: Provide details to the image(s) e.g. annotations, markers, or measurements.

Software Type

Software Name Optional

Select...

The name or type of software having the needing assistance. Start Date

Please select Critical as the priority for any temps starting within 24 hours or on a weekend/holiday. Study Correction Action Optional Select which action(s) to perform from the options below.

ALL Images

Paperwork ONLY

Specific Series

Specific Images

Patient Name

Patient DOB

Correct Report

Other (specify)

Study Correction Action Optional Select from the options to below which action to perform.

ALL Images

Paperwork ONLY

Specific Series

Specific Images

Study Correction Type Select the type of study correction to be performed.

Delete Images

Move Images

Correct Demographics

Suspicious Activity Observed Optional Please tell us what suspicious activity is happening on your computer.

System Requiring Password Reset

Temp Agency

This field is required.

Temp System Access Request Optional Select all systems the temporary agent will need access to.

Windows

RIS

Synapse

IntelePACS

Temp Tech Forms Optional Please indicate if the corresponding forms have been uploaded.

Confidentiality Form

Technologist Credentials

Position Select all that apply This field is required.

CT Tech

MR Tech

US Tech

XR Tech

Mammo Tech

Other

Username Special Requests Optional

Computer

Direct phone line

Docking Station

Laptop

Local Printer

Monitors

Phone

Phone Headset

Vendor Support Optional

Vendor is currently onsite to troubleshoot this issue

Vendor is scheduled for onsite visit to troubleshoot this issue

If you believe that your computer has a virus PLEASE REMOVE THE DEVICE FROM THE NETWORK BY UNPLUGGING THE NETWORK CABLE Optional Worklist Issue

Order Not Populating On Worklist

Order Not Dropping Off Worklist

Slowness

Worklist Type Select the system you are experiencing difficulties with.

InteleViewer Worklist

Modality Worklist

PowerScribe Worklist

Allowed Amount Optional Patient Responsibility Optional Patient Email Address Optional Insurance Adjustment Optional Reason for Request- Coding

Select...

Reason for Request- Claims

Select...

Patient DOB Date of Service New or Existing Exam?

This is a new exam

This is an existing exam

CPT Code and Description Enter the CPT code and the exam description. CPT Code and Description Optional CPT Code and Description Optional CPT Code and Description Optional Default Duration [minutes] Enter the default duration for this exam Default Duration [minutes] Optional Default Duration [minutes] Optional Default Duration [minutes] Optional Center List Select all applicable centers or use Center Groups selection above.

ALN

ASI

BED

BLD

BWI

CLE

CRK

CSI

DES

FRI

HCH

HCR

HDH

HDW

HFC

HLM

HND

HSL

HSP

HUL

HWL

KEL

LAC

LAF

LAM

LSM

MAN

MCK

MWI

NAR

OCC

OCL

PEN

PLA

SAR

SDI

SLA

SWF

TFI

TUL

TYA

TCL

UBT

UDR

WHP

WLK

WLM

WPK

WSL

WYL

Center Groups Optional If exam(s) to be added to all centers in a group select group(s) below.

Envision Imaging

Health Images

Lafayette

Orthopedic Centers of Colorado

Tulsa

For New Exams: Study Has Contrast Optional Yes No For New Exams: Study Requires Supervising Physician Optional Yes No For New Exams: Procedure Count Optional Enter the procedure count if equal to anything other than one. Radiologist Name (Full Legal) a. Full legal name/name the Rad uses for report signature, if different from full legal name. Updated Physician Name Enter the complete name name as it should appear after the update e.g. Jane T Doe [REQUIRED]. Physician ID Enter the eRIS physician ID for the affected account. If multiple accounts are affected enter additional ID(s) in message field [REQUIRED]. Radiologist Group Radiology group the Radiologist is assigned / working with.

Envision Internal

CIA

Diversified

RANT

RIA

TRA

Fidelis

BRRG

CHPG Breast Group

National Rad

NOIA

UC Denver MSK

Radiologist NPI number Optional Add group to existing drop down Optional add a group to a centers drop down Employee Name Clinical Systems Access requester

3rd Party Clinical System Requested

Name of the system requested

Other System Requested Optional Type the name of the 3rd party clinical system requested. Access Justification Reason for need of access to 3rd party clinical system. Director Approval Directors name who will be approving the request. PACS System/Location

Select...

Please select the PACS system and validation queue (if applicable) Validation Issue (select all that apply)

No order to attach study to

No patient name

No referring physician

No report in Ambra

No study description

Outside of 14 day window

Other

Patient Name Optional You may optionally upload a screenshot MRN Optional Accession Number Optional You may optionally upload a screenshot Study Date/Time Optional You may optionally upload a screenshot Modality Optional You may optionally upload a screenshot Study Description Optional You may optionally upload a screenshot Radiologist Start Date

Enter the date the radiologist will begin reading studies. Radiologist Name Enter the Radiologist's first and last name. THR Username Optional Enter the radiologist's THR user account. If not available specify reason below. Request By Enter the first and last name of the requestor. Requestor Phone Number Radiologist HL7 [OBR 32] Name Optional Enter the radiologist's name as it will appear in the HL7 message e.g. John Smith may appear as Smith^John. Reason for Study Correction Optional Please note the reason for study correction. Radiologist Interpreting Centers Optional List the market and centers the Radiologists will be working for. Supervision Centers Optional Is Radiologist supervising? What centers? Radiologist Dropdown Optional Add Radiologist to the drop-down list?

Yes

New or Modify

Is this for a new Radiologist, or a modification to existing?

Changes to Existing Radiologist Optional What changes need to be made. Interpreting RAD Drop Downs Optional Add Radiologist to the Following Centers Interpreting Drop Down Supervising RAD Drop Down Optional Add Radiologist to the Following Centers Supervising Drop Down Printer or Scanner type Optional Listing for the type of printer or scanner

Printer / Desktop

Printer / Dymo

Printer / Main

Scanner / Canon

Scanner / Epson

Scanner / MagTek

Location of file Ex. \\server\folder\file name Name of File Enter in the name of the file you would like restored. Type of file note the file extension or program to open the file with. File date

Date that you would like the file restored to. Candidate Name Please enter the name of the candidate ACCOUNT 1: Name of account owner First & Last name of account owner. **This field is required. ACCOUNT 2: Name of account owner Optional First & Last name of account owner. **This field is required if requesting more than one account. ACCOUNT 3: Name of account owner Optional First & Last name of account owner. **This field is required if requesting more than one account. ACCOUNT 4: Name of account owner Optional First & Last name of account owner. **This field is required if requesting more than one account. ACCOUNT 5: Name of account owner Optional First & Last name of account owner. **This field is required if requesting more than one account. Name of referring office **This field is required. Referring Office Phone Number **This field is required. Imaging System(s) **This field is required.

Ambra

IntelePACS

PAL

Synapse

Job title of account owner Optional Job title of account owner Optional Job title of account owner Optional Job title of account owner Optional Job title of account owner Optional Email address of account owner **This field is required. Email address of account owner Optional **This field is required if requesting more than one account. Email address of account owner Optional **This field is required if requesting more than one account. Email address of account owner Optional **This field is required if requesting more than one account. Email address of account owner Optional **This field is required if requesting more than one account. Employee Name Enter Name Employee Location Enter your work location. Name Change Information Optional If you had a name change, you will be required to send a copy of your updated driver's license and social security card to Human Resources, upon request.

New position or backfill

Is this a new position or backfill?

Position Title Optional Enter in the title for position requested

Position Type

Select the type of position.

Is this a remote position?

Yes

Hiring Manager Name of supervisor or manager for this employee. Are there any other managers you would like to share this requisition with? Sharing the requisition provides the opportunity for other managers to view candidate applications for the position. Any specific skills or behaviors you would like for recruiting to screen for? Optional Salary Information Optional Input the hourly or annual salary you would like to offer to the candidate. Pay will be determined based on the candidate's experience in conjunction with our current Compensation Philosophy. Email Address Requested by

Select...

Profile Request Type

What type of account request are you submitting?

User Name What is the user name? Enter your email address Position

Company

Which center / organization do you work with?

Center or Location

Which center or location do you work at?

Department

New Vendor Name or Vendor Name Change Enter the name of the new vendor, or provide the vendor name to change to. Vendor Remit Address address where payments are to be mailed Vendor Contact Information

Payment Type

Choose payment type

Bank Routing Number Bank Account Number

System

Are you submitting a request for Beanworks or IOS?

Invoice Number Invoice Amount Date of Invoice Upload Optional

Acctg-AP\Invoice Issues

Use this form if you need to report an issue with an invoice

Vendor Email Address Event Name Dollar Amount Requested Recipient/Payee Address

Event Category

Recipient/Payee Invoice Purpose/Type Optional Enter the type of invoices for the vendor. Rent, IT equipment, services, etc. Impacted System Which system (i.e. RIS, IntelePACS, Fuji Synapse, Network) will this change potentially impact? Date of Change

Date of proposed change Who is performing change? List the primary IT resource responsible for this change. Additional Resources / Mobile List any additional resources involved with this change, as well as contact information. Impacted Users Centers, departments, or application users impacted by this change. Change Description Describe the change being made, including current state vs desired state, testing plans, and factors used to determine if this is a successful change. Rollback Plan (if needed) Describe what steps will be taken if this change is not a success, including details around the go/no-go decision and how the original environment will be restored.

Change Type

Routine/Recurring - A planned change that happens on a schedule more than once. These can be scheduled up to (1) year out at which time a new request must be submitted. Normal/Planned - Agreed time when an IT Service will not be available. Planned change is often used for maintenance, upgrades and testing. Emergency - A Change that must be introduced as soon as possible. For example, to resolve a Major Incident or implement a Security patch. Any change that is submitted less than 1 week prior to needed implementation with proper justification and approval.

Severity of Change

Major - The highest risk category for potential Impact. A major change to critical processes that will cause a significant disruption to the Business and end user processes. May require downtime. Significant - Change is nonstandard and may require a downtime, poses a high risk to delivery of IT services. A high percentage of end users will be affected. Minor - Routine operational changes that pose low risk to delivery of IT services, only a small percentage of users will be affected. Standard - Routine operational changes which pose no known risk to the delivery of a service.

Mobile Mobile number (or best contact method) UKG Report Recipients Optional Please indicate who should receive the requested report. Report Details Please indicate what type of information you are requesting and how the report will be used. This would be helpful to get an idea of what type of content/data should be included on the report. What is the best phone number to contact you? Contact Name Manager Optional Please enter your supervisor or manager's name. Start Date for Cross Training Optional

Cross Training End Date Optional

Area of Interest for cross-training Optional Please provide a description of the type of cross-training you'd like to have. Type of Training Requested Optional Date working interview is scheduled to be completed:

Reminder: Human Resources must receive at least 24-hour advanced notice to allow time to prepare federally required documentation for the candidate. Leave Start Date Optional

Enter the date that the leave will start. Estimated Return Date Optional

Enter the date of estimated return from your leave of absence. Date Starting Work from Home Optional

Please identify the start date for WFH. Estimated Return Date to Center Optional

Please enter the estimated date of return to the center. Operating System Optional Please select the type of system the staff member will be using from home.

Windows

Apple - Macintosh

Other (Chromebook, etc)

Center Extension for use Optional Please identify a center extension that the staff member will be using from home. Antivirus Needed Optional Please select whether anitivirus (Kaspersky) is needed on the home computer.

Yes

I don't know

Current Version of Office (if known) Optional Please indicate what version of Office is currently installed, if applicable. Reason for Medical Leave of Absence Optional Please provide a brief explanation for the Medical Leave of Absence need. Start Time List proposed start time for the change. Anticipated Duration How long should this change take to complete? Reason for Change Break/Fix Upgrade Additional Features Marketer RIS Group Name Volume Enter the approximate volume per month. System Requirements Please enter: - System Name - Software Required - Web based access Number of Licenses Please enter: - Number of licenses available - Cost per license, if applicable Special Requirements Optional Please indicate any special requirements that might be needed. Concierge Request Yes No Please indicate if this is a concierge request. Practice Contact 1 Please include: - Name - Phone - Email Practice Contact 2 Optional Please include: - Name - Phone - Email Expected Date of Deploy

Name of Requester Please provide either the name of the marketer or request in this field. Office Name In the subject line please indicate 'New EMR Request - (Office Name). Please also indicate the office name here. Office Address Please provide the full address of the office(s). Alternatively, a document can be attached to the 'upload files' section.

Orders and Results

Please select the type of request.

Office Point of Contact Please indicate the name, email and phone number for the office. Office IT Contact Please indicate the name, phone number and email for the IT point of contact for the office. EMR Vendor Contact Info Please indicate the name, phone number and email address for the EMR vendor point of contact. Provider List Please list the name(s) and Physician NPI(s) for each provider from the practice. Alternatively a document can be attached to the 'upload files' section. Provider Name Please enter the name of the provider as it is associated with their NPI. Multiple providers can be separated by commas. Provider NPI Please enter the NPI for the provider. Multiple NPIs can be entered separated by a comma. EMR Issues In the subject line please indicate EMR Issues - followed by the office name. Describe the issue with the EMR providing as much detail as possible. PLEASE INCLUDE EXAMPLES TO INVESTIGATE. (i.e. not sending orders, not getting results, errors) EMR Vendor Please indicate the vendor of the EMR. Payroll Request Modification Provide details on the request

EMR Type

Please select the appropriate EMR from the dropdown below. If you select other, please add the name of the EMR vendor in the message dialogue box.

Number of Providers Requested Please enter the number of providers here. Additionally, please include the provider details in the box below, including NPI Timeline Agreement Thank you for your submission. The average EMR project may take up to 30-60 days for completion depending on the consistency/accuracy of responses by all parties involved.

I Agree and Understand

Existing Office Name In the subject line, please enter 'Existing EMR Configuration - (Office Name). Please also enter the office name here. Number of Physicians Please indicate the number of physicians requested to inactivate. For more than one physician please enter one name in the form and the additional names attached on a spreadsheet. Physician First Name Physician Last Name Physician ID Please enter the physician ID. Physician Address Please enter at least one physician address. For additional addresses please upload a spreadsheet. Date of Inactivation

Please select the date physician stops working at location.

Reason for Inactivation

Please select the reason for inactivating the physician.

Inactivation approved/initiated by

Please indicate who approved or initiated the request for inactivation. Please provide additional detail if 'other' is selected.

Name of Approver/Initiator Please provide the name of the person who approved/initiated the removal of the physician. Physician ID Please enter the Physician ID you would like to keep. Physician ID (Deactivate) Please enter the Physician ID you would like to deactivate. Physician Address Please enter the address listed on the physician account you would like to keep. Physician Address Please enter the address listed on the physician account you would like to deactivate. Reason for merging Optional Please enter reason for merge (duplicate, etc.) Reason for reactivation Please enter reason for reactivation.

Inactivation approved/initiated by

Please indicate who approved or initiated the request for reactivation. Please provide additional detail if 'other' is selected.

Name of Approver/Initiator Please provide the name of the person who approved/initiated the reactivation of the physician. Date of reactivation

Please enter the date of physician reactivation. Physician Address Please enter physician address including city, state and zip code. Physician Phone Number Physician Fax Number Physician Group Physician Specialty Physician NPI Optional Report Delivery Method

Fax

Notify

Mail

DACBR Interpretation

EMR

None

Film Delivery

None

Film

CD & Film

CD with Patient

Film with Patient

CD to Attorney

Film to Attorney

To Physician PACS

CD & CD with Patient

Mail CD

What are we updating? Please specify what needs to be updated in the account. Which radiologist is preferred? What center(s) would you like this radiologist assigned to? Enter one or more center abbreviations to assign the preferred radiologist to. Who is initiating/requesting the assignment of the preferred radiologist? Please enter name and position title of who is requesting the preferred radiologist be assigned. Who is the person requesting the report? Please enter name and position/title of person requesting the report. When do you need this report by?

What kind of report do you need? Please enter ALL details and information needed in the requested report. What is the physician's current group (if any)? What group is the physician currently assigned to (if any)? What is the new/updated group? What is the new/updated group the physician needs to be changed to?

Who is the current marketer?

Who should the marketer be?

Reason for changing marketer? Why are we updating the marketer? If it is an error just put "error". This is NOT for updating null marketers.

What type of training do you need assigned?

Please select the type of training needed

Purpose for training Please provide a detailed description statement. Training Mandatory Please select yes or no

Yes

What is the incorrect physician name? What is the corrected physician name?

What is the reason for correcting the name?

What is the purpose? Please provide a detailed description statement. Is this training mandatory?

Yes

When do you expect the training to be administered? Please provide an approximate date and timeframe as this will help prioritize the development and/or availability.

How often will you need a report?

Please choose how often you will need a report of this training.

Do you need assistance with training? Do you need assistance preparing your training to post in UltiPro Learning? (Ex: creating a quiz, formatting, saving appropriate file type, etc.) Additional comments about training needs: Optional Type of development support needed:

I need assistance with concept, flow, or storyboarding

I need assistance with images, shapes, video or sound

I need assistance with adding audio recording to a presentation - If yes, do you need to borrow equipment?

I want to request the Corporate Trainer to record content

Other - Need other support.

Your name: Your email address: Optional What is the best phone number to reach you? Type of assistance required What type of assistance do you require? Do you need assistance with a course assignment issue? Such as assigning or unassigning. Optional Do you need assistance with a course assignment issue? Such as assigning or unassigning. Are you having an issue with a training not marking complete, despite multiple attempts? Optional Do you need assistance with Third Party Access or CORHIO? Optional Please add any additional information regarding your request. Optional Which topics are you interested in? Please select which topics you are interested in.

Learning to Lead

Change Management

Public Speaking

Appreciation/Recognition*

Difficult Conversations*

Customer Service*

Other, please indicate in notes

How many attendees do you anticipate? Who will be the audience? Such as department, job type, or provide a list of attendees. When would you like the training?

What is the group/office name in Salesforce What is the Salesforce Contact Name? Optional

What are we doing?

Who approved this change? Who is the current owner of this record? Who are we changing the record owner to? (If applicable) Optional Please fill out this question if you are requesting a record owner change. What are we doing in Salesforce? Please list what you are requesting to be done in Salesforce.

What call cycle are we changing to?

Please select from the drop down if requesting a call cycle change.

What are you requesting? Overread Location(s) Optional Select all applicable groups.

CMC

CPMC

CRFP

DAC

DAOM (NO CIA Coverage)

FCN

FFM

MOM

QCMD

QCMDB

QCMDG

MNOWA (NO CIA Coverage)

QCMDS

QCMDP

SHC

RMIM (NO CIA Coverage)

SHPA (NO CIA Coverage)

UAL [aka Southern Urology]

SHPD (NO CIA Coverage)

SHPT (NO CIA Coverage)

SZC

IT: Change Communication Plan Optional Who needs to be notified when, by whom, and through which method? Is there anyone whom needs to be CCed in this request? Optional Please provide email address for all CC needed. What specific accommodation(s) are you requesting, if known? Please provide a summary of work accommodation(s) you would like to request for review. If you are not sure, input "Unknown". Your designated HR representative will be in contact for additional information. What is the expected duration of the requested accommodation(s)? Add the timeframe you expect to perform the requested work accomodations. Request for Benefit Information / Claim Forms Optional Use this form to request benefit information and/or claim forms.

401k

Aflac (Accident or Critical Illness)

Dental

ESOP (Employee Stock Ownership Program)

Flexible Spending Account (FSA)

Group Term Life Insurance

Health Savings Account (HSA)

LifeLock - Identity Theft Protection

Long Term Disability

Medical

PetPartners

Short Term Disability

Supplemental Life Insurance

Vision

Please describe what information/documentation you need. New Mailing Address (Please include street address, city and zip code information.) Optional Please summarize support needed with UKG Pro Candidate Name What position is the candidate interviewing for? Time working interview will be completed: Is this a new temp request or an extension to an existing tech?

New Temp Request

Existing Temp Extension

For extensions only - Name of Temp Account Being Extended (ex: TFITEMP03). Must be the same center and tech already approved for coverage. Optional Please include the temp account already being used if possible. Select the behavioral/performance concern(s) from the list below.

Absenteeism/reliability

Accountability

Accuracy

Attendance

Attention to detail

Cell phone use

Certification

Communication in the office

Confidence

Consistency

Customer service

Following established guidelines

Following management directives

HIE / Pregnancy question

HIPAA

Leadership

Patient safety

Problem solving

Professionalism

Protocols related to MD orders

Quality of scans

Retention of office protocols

Teamwork

Other, not listed

Describe the behavioral and/or performance concern(s) Describe the type of coaching sessions held to address behavioral/performance concern(s) Describe the latest incident. What is your recommended course of action to take to address concern(s)?

Verbal coaching session with email follow-up

Counseling Memo

Performance Improvement Plan

Termination

Unknown, need advice

Type of change Please select, from the list of options, the type of change you are requesting.

Allocations

Benefit(s)

Classification (i.e. full-time, part-time, PRN (As-Needed))

Job title

Pay adjustment

Supervisor

Weekly work hours

Work location

Work schedule

Other, not listed

Details of the change If change involves a promotion, should the employee’s wages be allocated? Optional Yes No How should the wages be allocated? Optional

Even allocation – all centers

Even – CHER Centers

Even – HIP Centers

Even - OCC Centers

Even - TUL Centers

Even - CHER/CSI Centers

Other, indicated on change form

N/A

Last day the employee worked or will work

Select the last day the employee worked or is expected to work. Additional details regarding employee’s decision to resign Optional Add any additional details regarding the employee's reason for resigning from their position. Have there been any issues leading up to the employee’s decision to resign? If so, please provide a brief summary of events. Optional Eligible for rehire? Optional Yes No Reason for resignation: Select the reason(s) the employee resigned from their position.

Compensation

Death

Dissatisfaction with job

FMLA / Medical leave of absence exhausted

Job abandonment

Lack of work

Moving

No reason given

Other job

Other reason(s), not listed

Personal reason(s)/family

PRN (unavailable)

Retirement

School

Working interview

Classification

Full-time

Part-time

PRN (As-needed)

Reason for your request for involuntary termination

Failed background check

Death

Excessive absence/tardy

Gross misconduct

Performance

Reduction-in-force (RIF)

Theft

Violation of company policy

Provide a summary of performance concerns What was the final event(s) leading to the decision to terminate the employee? Describe any recent changes to job expectations, software, etc. Optional If this is a classification change, select the type of change. Optional

Increase in hours: Part-Time to Full-Time

Increase in hours: PRN (As-Needed) to Part-Time

Increase in hours: PRN (As-Needed) to Full-Time

Reduction in hours: Full-Time to Part-Time

Reduction in hours: Full-Time to PRN (As-Needed)

Reduction in hours: Part-Time to PRN (As-Needed)

N/A

Effective Date

The effective date must be the beginning of a pay period. Job Summary/Objective Should provide an overview of the company or department and expectations of the job. Essential Functions Include a brief outlines of the essential tasks of a job position and establishes a guideline for the position. These are duties/responsibilities the position is expected to perform as regular activity. Competencies List the knowledge, skills and abilities, and other requirements that are needed for someone to be successful in this position. For example: Communication, Financial Management, Technical Capacity, etc. Will this position have supervisory responsibilities?

Will have supervisory responsibilities – with direct reports

Will have supervisory responsibilities – without direct reports

Will not have supervisory responsibilities

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Work Environment

This job operates in an environmentally controlled outpatient clinical environment. Potential exposure to radiation, which is minimized by the use of Personal Protective Equipment. Possible exposure to bodily fluids, communicable diseases, toxic substances, ionizing radiation and other conditions common to a medical office environment. Often requires work in cool, dimly lighted rooms.

This job operates in an outpatient clinical environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

This job operates both in-the-field and in clinical environments. Automobile travel is required on a daily basis. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

This job operates in an office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

Is travel expected for this position?

Travel is expected for this position

Travel is not expected for this position

What are some of the minimum job qualifications for this position? Document the minimum job qualifications for this position. Examples: • Detail oriented, self-motivated, a problem solver and a team player • Ability to navigate multiple computer screens and browsers quickly and accurately • Ability to excel in a very fast-pace team environment • Ability to continuously “exceed” company and customer expectation • Strong communication skills & professional demeanor What is the minimum education necessary to perform this position?

G.E.D.

High school diploma

Associate's Degree

Bachelor’s Degree

Master’s Degree

Doctoral or Professional Degree

No preference

Certification(s) Required Optional

ARDMS (American Registry for Diagnostic Medical Sonography)

ARRT (American Registry of Radiologic Technologists)

Bone Densitometry

Breast Sonography

CT (Computed Tomography)

Mammography

MRI (Magnetic Resonance Imaging)

Nuclear Medicine

Sonography

Texas Medical Board (TMB)

X-ray

Other(s), not listed

Please list additional certification requirements, if not provided above. Optional Please provide any additional eligibility qualifications necessary for this position. Optional OSHA Exposure Rating Based on the job expectations for this position, select the potential OSHA exposure rating.

OSHA Exposure Rating: 1 It is reasonably anticipated NO employees in this job classification will have occupational exposure to blood and other potentially infectious body fluids.

OSHA Exposure Rating: 2 It is reasonably anticipated SOME employees in this job classification will have occupational exposure to blood and other potentially infectious body fluids.

OSHA Exposure Rating: 3 It is reasonably anticipated ALL employees in this job classification will have occupational exposure to blood and other potentially infectious body fluids.

Reports To Include the job title of the person this position will report to. Department Select the department this position will work out of.

Accounting

Accounts Receivable

Administration

Benefits

Centralized Services Reps

Development

Executives

Human Resources

Information Technology

Managers

Marketers

Medical Records

Patient Care Coordinators

Patient Service Reps

Payments

Quality & Safety

Strategy & Decision Support

Technologists

Transcriptionist

Job Title Region

CHER

CSI

HIP

LAF

OCC

TUL

CCM

UMIP

What policy or employment law do you require assistance with? Please provide specifics. Name of individual this position will report to: Who will be the Onboarding owner once hired? This person will be responsible for being the first contact for the employee on their first day and complete Section 2 of the Form I-9. Reason for opening

Backfill or replacement

New headcount

Overhire

Temporary/Seasonal/Special Project

If this is a backfill, what is the name of the employee who is/has resigned or transferred? And what is/was their last day worked? Optional What is their reason for leaving or transferring out? Optional What days will this prospective employee be expected to work?

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

PRN (As-Needed)

What hours? Is overtime expected? Yes No Last Day Worked Optional

Is travel expected for this position? Yes No If travel is expected, how much travel would you anticipate on an annual basis? Optional

1-25%

25-50%

50-75%

75-100%

Which center(s) will this person work at? If multiple, please indicate which center will be their primary location. If so, please indicate how much. Optional What type of request are you submitting?

Create a new job description

Update an existing job description

Select the applicable qualifying life event: Please note that we will require supporting documentation of your loss or gain of coverage. If you have supporting documentation available at the time of submitting this request, please upload it below.

You or a dependent lose job-based coverage

You get married

You have a baby

You adopt a child (or other dependent)

You get divorced (or legally separated from your spouse)

Reason for requesting FMLA

Birth and care of a newborn child

Placement of a child for adoption or foster care

To care for my spouse, child or parent who has a serious health condition

A qualifying emergency arising out of the fact that my spouse, son, daughter or parent is a military member on covered active duty or called to covered active duty

To care for a covered service member (who is my spouse, son, daughter, or parent) with a serious injury or illness for who I am next of kin

What type of FMLA absence will you require? Optional

A temporary reduced work schedule

Leave for a continuous block of time

Leave to be taken on an intermittent basis

Where would you like this requisition to be posted? Please indicate whether you would want this position to be posted for internal and/or external applicants to see.

Both external and internal

External only

Internal only

Issue Type Select the concern(s) you would like to speak to human resources regarding.

Benefits

Compensation / Pay

Compliance concern

Concern(s) with Co-worker

Concern(s) with job

Concern(s) with Manager/Supervisor/Lead

COVID-19

Harassment

Leave of absence

New hires

Safety concern

Termination

Timekeeping

Training

Violation of company policy

Work accommodation

Workers compensation

Other, please provide details in the message section.

FLSA Status

Exempt

Non-Exempt

Who will need to be assigned the training? Optional

Corporate

Leads

Managers

Marketers

Operations/HUB

Other

Patient Care Coordinators (PCCs)

Patient Service Representatives (PSRs)

Technologists

Where would you like the training to occur?

Offsite location, if offsite please indicate who will arrange the meeting accommodations in notes

Onsite at Corporate or Operations

Virtual

Other, please indicate in additional comments.

What are some of your expectations for the employee to improve? Include specific expectations you have for the employee to improve in the areas you indicated above. Do you want to extend a sign-on bonus for eligible external candidates? Note: We currently offer sign-on bonuses in the amount of $1,500 or $2,500 to be paid in three pay increments: 1. At the time of hire 2. After completing 6 months of employment. 3. At 1 year of employment. For any amount higher, please obtain approval from senior management. For any amount above $2,500, approval will be required by senior management. Multiple Office Locations Yes No Does the office indicated have multiple locations? What date range should be considered in the data? The date range which is relevant to your request. I.e. yesterday's data, tomorrow's data, the last six months of data, etc. What question are you looking to answer with this report? List a detailed description stating why you need the data. This will help us better compile the appropriate information for you. This should also include parameters if you're looking for specific information around certain centers, modalities, users, etc. What fields should be included in you data? This could include modality, physician's office, insurance company, etc. Does the user have an existing Tableau license? If no, please first place a ticket under Tableau User Licensing. Yes No Who needs access to an existing Tableau Report? What reports do they need access to? Please provide the URL. copy and paste the web address for the report. What report is this in reference to? Who Needs Access? Do you approve the associated costs with licensing? Yes No A tableau license currently costs $420 per year allocated to the licensed user's department. What report is experiencing the issue?

What kind of report problem are you experiencing?

Resource Description Center Name What schedule type(s) are you updating? Select all that apply

Normal Operating Hours

Online Scheduling

Contrast Hours

Please provide the updated times for each resource, schedule type, and weekday. i.e. Operating Hours, MRI 3T, 9:00am - 5:00pm M-F and 10:00am-2:00pm Saturday. What type of Salesforce report do you need? What date do you need this report by?

Decision support receives a lot of request. Understanding the date it will be critical to have your report will help us prioritize this request. What is the Salesforce office ID? What is the Salesforce office name? Who is the office owner? What kind of changes are needed? What is the Salesforce contact name? What is the Salesforce contact id? Who is the contact owner? Is this for a physician with no Sales Account Manager selected? Optional Yes No Physicians with missing Sales Account Managers are regularly identified by the Decision Support team and updated on Tuesdays and Fridays. If the physician is still not assigned to you 1 week after the referral date then please use this form to notify. What Sales Account Manager should be assigned? Is this request for a one time report file and not a new Tableau report? Yes No This form should be utilized for one time reporting requests only. New Tableau reporting should be directed through Decision Support in collaboration with your leadership when appropriate. Original Medical Record Number MRN to be Deactivated Additional MRN to be Deactivated Optional Patient Name Patient DOB Region

Texas

Colorado

Louisiana

Utah

Oklahoma

Repair Location Please provide a description of where the service is being requested. Furniture/ Equipment Requested Please detail what furniture/ fixtures are needed or what equipment will need to be ordered / replaced. Incident Response - Description Optional Please describe the incident in detail. Incident Response - Status Optional

Suspected

Confirmed

False

Incident Response - Indicator Optional

Minor

Major

Severe

Incident Response - Handlers Optional Please indicate who is working the incident. Incident Response - IRT Optional Yes No Has the incident response team been convened? Incident Response - IRT Members Optional Please indicate the members of the IRT if they have convened. Incident Response - Mitigation Optional Please detail the steps for mitigation with the response. Incident Response - Recovery and Monitoring Optional Please provide details regarding the recovery of systems and monitoring in place following the incident. Incident Response - Reporting Optional Please provide any reporting for the incident. Incident Response - Breach Indicator Optional Yes No Did a breach occur with the incident?

Centers Only. Please select.

Please select one of the following position types.

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