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IT Staff Only Output Printable Report Download File MIS Form ID for ELR Document If download file Output Format Delimiter Project Tracking HCIS Tracking Heat Date Received IT Authorization Contact Person Assigned To Date Assigned Date Completed NPR Report Name Original 4/15/04 Modified 5/17/04 Modified 11/07/08 The User Request Information Section must be filled out completely The Date Needed Section must be filled in with a date. Facility Contact Information Catholic Health East NPR Request Form Instructions for Completion of Request Form Requesting Facility Request Date Requestor Name New Change Copy/Change Title Requestor Phone Ext Requestor E-mail Beeper Department Name Department Management Approval Printed Signature Detailed Description of Request Attach additional sheet if necessary Frequency DPM if known User Request Information Date Needed Module Data Sort Order Name of Report Copy report from if applicable Selection Criteria How the system will determine to extract the data you wish to view. For example View all self-pay Pediatric visits from between date ranges that are specified at report time. Data to be included on report Patient Name Acct Attending Physician etc* Specify formulas or any calculations unique to this request. Designate where any subtotals or totals are to be printed* Attach an example format if needed for clarification purposes. Exclude confidential patients from report Yes No Report impact List purpose of report and impact on customer satisfaction patient care and/or revenue. If no date is filled in please expect 10 business days for request to be completed* Note ASAP is Unacceptable. Requests will not be accepted without Department Management Approval Signature. Provide as much detail as possible when completing this form* Attach examples whenever possible. If the User Request Information Section is not complete this form will be returned to originator for completion* Please expect approximately 10 business days for request turnaround. For example View all self-pay Pediatric visits from between date ranges that are specified at report time. Data to be included on report Patient Name Acct Attending Physician etc* Specify formulas or any calculations unique to this request. Data to be included on report Patient Name Acct Attending Physician etc* Specify formulas or any calculations unique to this request. Designate where any subtotals or totals are to be printed* Attach an example format if needed for clarification purposes. Designate where any subtotals or totals are to be printed* Attach an example format if needed for clarification purposes. Exclude confidential patients from report Yes No Report impact List purpose of report and impact on customer satisfaction patient care and/or revenue. If no date is filled in please expect 10 business days for request to be completed* Note ASAP is Unacceptable. Requests will not be accepted without Department Management Approval Signature. Provide as much detail as possible when completing this form* Attach examples whenever possible.

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