New Document/Form Request
FROM
REPLY
example@example.com
Complete
Department
Branch
First
Last
ID
Name of person requesting:
*
Title:
*
Department making request:
*
Please Select
Billing
Branch Mgrs
Carespecialist
CDPAP
Compliance
Coordination
Human Resources
Nursing
Payroll
PR
Recruitment
Waiver
Is it an internal CCHHS document?
*
YES
NO
Is it a document provided by a third-party:
*
YES
NO
If YES, what is the name of the organization?
*
Current document status. (check one)
*
Existing document that needs to be updated.
New document that needs to be created.
What is the title of this document/form?
*
Document/form Structure – select one.
*
This is a standalone form.
This form will be included in a packet.
Both of the above.
Select packet type.
*
New packet being created.
Adding this document to an existing packet.
What is the name of the new packet?
*
What packet(s) does the form need to be added to? Select all that apply.
*
Acaria Packet
Admission Nursing Packet
Admission Nursing Packet
Admission Packet
Aide Supervision Packet Annual
Aide Supervision Packet Annual
CDPAP Consumer Intake Packet
CDPAP Equal Employment Opportunity Packet
CDPAP Monitoring Report Packet Abridge
CDPAP Monitoring Report Packet
CDPAP PA Application Packet
NP Medical Packet
Patient Financial Intake
Patient Payment Authorization Pack
Patient Payment Authorization
Pre Employment Screening 1 2024
Pre Employment Screening 2
Reassessment Packet
RN Admission Clinical Packet
RN Admission Clinical Packet
Service Agreement Packet
Services Financial Packet
Skilled Care Infusion Packet
Skilled Care Packet
Skilled Nursing Med Pour Packet
Skilled Nursing Shift Packet
Skilled Nursing Visit Packet
Waiver HCSS Documentation Packet
Waiver HCSS Training Packet
Waiver Home Abstract Assessment
Waiver Intake Packet
Waiver NHTD TBI Training Packet
Waiver NHTD TBI Training Packet
Include in these packets.
Upload a sample of the document you want.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Does it need to be emailed to someone be signed and dated?
*
YES
NO
Do they also need to fill out any other fields of data?
*
YES
NO
Will this document/form be used by the whole company?
*
YES
NO
If NO, indicate which locations need it. (select all that apply)
*
Buffalo
Queens
Rochester
Smithtown
White Plains
Should the document be included in Audits?
*
YES
NO
What applications will this document/form be used in? Select all that apply
BOLT
naturalFORMS
Jotform
Provide a reason why this new document/form is needed.
*
Back
Next
Document Processing - Workflow
Does the document need to be faxed/emailed to anyone?
*
YES
NO
If YES, provide the following.
Company Name:
*
Select the delivery method.
*
FAX
EMAIL
Fax Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Which department(s) need to receive and email notification with attachment of the submitted document? (select all that apply)
*
Billing
Branch Mgrs
Carespecialist
CDPAP
Compliance
Coordination
Human Resources
Nursing
Payroll
PR
Recruitment
Waiver
What Catalog in Content Central will this document be saved to? (select one)
*
Caregiver
CDPAP
Corporate
Patient
Executive
What Caregiver subfolder will the document be saved to? Select One.
*
Background Check
Benefits
Compliance
Employment
HR Documents
Medical
Payroll
Performance
Policies
Tax Forms
Waiver
01 Caregiver
What CDPAP subfolder will the document be saved to? Select One.
*
Admissions
Benefits
Compliance
Confidential
Employment
HR Documents
Medical
Payroll
Policies
Tax Forms
01 CDPAP
What Corporate subfolder will the document be saved to? Select One.
*
Admissions
Benefits
Compliance
Confidential
Employment
HR Documents
Medical
Payroll
Policies
Tax Forms
01 Corporate
What Patient subfolder will the document be saved to? Select One.
*
Admissions
Benefits
Compliance
Confidential
Employment
HR Documents
Medical
Payroll
Policies
Tax Forms
01 Patient
What Executive subfolder will the document be saved to? Select One.
*
Admissions
Benefits
Compliance
Confidential
Employment
HR Documents
Medical
Payroll
Policies
Tax Forms
01 Executive
Subfolder
Additional Comments - Insturctions
Name
*
Title
*
Signature
*
Date
*
/
Month
/
Day
Year
Date
CCHHS STAFF REVIEW – OFFICE USE ONLY
Authorized By Name
*
Title
*
Signature
*
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: