IT Support Ticket
HIPAA Compliant
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Time
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Minutes
AM
PM
AM/PM Option
Your Name:
*
Client name:
*
Your Name:
Supplies and Quantity Needed:
Your email and/or callback number
*
Issue type:
*
Computer Issue
Phone/Internet Issues
Printer Issue
EMR Interface Issue
Client Portal Issue
Password Reset / Locked Out
Does your request contain PHI?
*
Yes
No
Description of Issue: (No PHI)
Description of Issue:(PHI Allowed)
Screenshot or document upload:
Level of urgency:
*
Low
Medium
High
Critical
Submit
Should be Empty: