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Provider request for new reports or report modification
Subject
A short description to explain the nature of a ticket.
Provider Agency Name
Provider Report Type
Provider Report Type
Report Access
New Report
Report Enhancement
Is this for an existing account?
Is this for an existing account?
Yes
No
Name of person needing access
Email of person needing access
Supervisor of person needing access
Email for supervisor of person needing access
Name of Report
Description of enhancement needed.
Description of new report needed
Attachment
File attachments associated with the ticket.
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Urgency
The importance of a ticket and how quickly it needs attention.
Low
Medium
High
Critical
Other Fields
Your name
Your first name
Your last name
Your email address
Your phone number
Verification Code