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CPH Information Technology Support Services

NextGen Ticket Request

Please select a request ticket type and click SUBMIT

Nextgen Ticket System

What type of Nextgen request would you like to make?

Type of Request

New User Access/Existing User Access

Report/Data Request

Enhancement Request

Chart Edit/Encounter Delete

Deactivate Accounts

Password Reset

Merge Records

Signature Pad

Fee Tickets

Scanner

Printer

Something is not working

OtherOther

Requestor Information

Name *

Name

First

Last

Email

Phone *

Division *

Program *

Job Class Title *

Floor Floor

Urgency *

Room # / Location

NextGen User Information

Please describe your issue or request in as much detail as possible.

Name *

Name

First

Last

Middle Initial

City Email *

Desk Phone *

Division * Division

Program *

Job Class Title *

Manager’s name *

User Permission(Name of co-worker with similar job responsibilities) *

Last 4 SSN *

Computer Username (eg. Tsmith) *

User Role * User Role

User Status *

Nursing Credentials (Complete as applicable)

Ohio Medical License #

NPI

DEA

Certificate to Prescribe (CTP)

Reason for Access Request (check all that apply)

Patient Treatment

Registration

Scheduling

Coding

Billing

Ryan White Case Management

OtherOther

IMPORTANT

1. The New/Existing User will receive Confidentiality Agreement attachment via city email after submitting the ticket.
2. Supervisor please have New/Existing User print their full name and sign the “Confidentiality Agreement” form using Acrobat Reader. Follow instructions linked to “Action Required” email for electronic signature.
3. Confidentiality Agreement form is also available on NextGen Intranet page under ” FREQUENTLY USED FORMS”

Report/Data Request

Type of Request * Type of Request

NextGen Program * NextGen Program

Report Title

Enhancement Request

Please describe your request in as much detail as possible.

Template Name

NextGen Program

EHR

PM

OtherOther

Please Note:

The first login Amazon Desktop Password expires every 3 months

Password Reset Type *

Device you are using *

Merge Duplicate Records

Client First, Last Name (#1) *

MRN (#1) *

DOB (#1) *

Last four of SSN(#1) *

Client First, Last Name (#2) *

MRN (#2) *

DOB (#2) *

Last four of SSN (#2) *

Record to Keep *

# 1

# 2

Patient Information

Client Name *

DOB *

MRN # *

Last four digits of SSN *

Encounter to Delete

Date *

Time *

:

Encounter Number *

Encounter to Keep

Date

Time

:

Encounter Number

Manager’s approval required to complete request

Manager’s Email: *

FOR MANAGER ONLY: Approve this change request?

I approve this request

I deny this request

Type Your Name *

Type Your Name

First

Last

Signature

Clear

Additional Comments (if necessary)

Scanner Information

fi-7160 Scanner Serial # (e.g. A12BF..)

Desktop Host Name (e.g. HD0125..)

Scanner Model # (e.g. P1234B)

Scanner Issues * Scanner Issues

Please Note: Printing Fee Tickets please set your printer location “set as default printer” under “Printers icon” on NextGen Desktop

Types of Issue * Types of Issue

Deactivating Account Information

Name *

Name

First

Last

Email

Effective From *

Username *

User Role * User Role

Program *

Deactivate Accounts * Deactivate Accounts

Reason for Deactivation * Reason for Deactivation

Printer Information

Name of Printer (e.g. HD-2B230) *

Desktop Hostname (e.g. HD0123) *

Type of Printer *

Printer Model (e.g. LaserJet M123)

Has this printer been used for NextGen before?

Yes, but it is not working for any users

Yes, but it is not working from this computer

No, this printer has not been used for NextGen before

Signature Pad

Which device is signature pad plugged into?

Desktop Computer

Laptop

Have you tried restarting your computer/laptop with the signature pad plugged in?

Yes

No

Something is not working

NextGen Program

EHR

PM

Appointment reminder

Other messages

OtherOther

Describe your request

Upload a Screenshot (Optional)

Maximum file size: 10MB

If you are human, leave this field blank.

This page is updated regularly. Please check back for the latest updates and guidance about this and other Information Technology topics.