CPR Add/Change EMR Form Request
This form is utilized to submit requests to make changes and/or additions to the EMR.
Email
example@example.com
Name
First Name
Last Name
Department
Job Title:
I am requesting to...
Create/add something new
Make changes to something that already exists in the EMR
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Request to create something new for the EMR
Potential Title/ description
Purpose/Goal of the addition
Main components / content to be included
Please notify me prior to changes being made
Yes
No/Not necessary
Optional: If you have created a template of what you would like the addition to look like, please feel free to upload to provide a better understanding of the request being made.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
costs to complete change -NEW
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Submit
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Request to make changes to something that already exists in the EMR
Name of forms, note, assessment, etc. requesting to be changed
Section(s) you would like changed (add, remove, edit)
Please describe the changes you are requesting to be made to the above sections
Please provide a reasoning for the change(s) to be made
Please list additional forms/notes/etc. that may need an update as a result of the above requested changes being made
Please notify me prior to changes being made
Yes
No/Not Necessary
Optional: You can upload screenshots of parts of the form/note/etc. you would like to be changed to provide a clearer understanding of the request being made.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Submit
Next
Costs to complete change -change/edit
****ADMIN AREA ONLY****
Priority
Mandatory/needed for day-to-day operations
Company-wide with multiple improvements
Legal/contractual obligation
Other
Programs/employees affected
Company-wide
Multiple programs
Singular program/team
Improvement(s)
Revenue generating
Compliance
Quality
Client care
Process (reduce time and/or effort spent on given activities)
Other
Other considerations
Cost
Time
Other
Submit
Should be Empty: