Submit a request – Forcura Circle

Your email address

Subject

Do not include PHI.

Company Name

Contact Phone Number

ex: 8005551234

Time Zone

EHR Support Ticket #

(if applicable)

What is your request for?

Browser

Device Make/Type (Ex: Samsung Tablet)

Device Model # (Ex: Samsung Galaxy Tab A SM-T295)

App Version? (found in Account Settings in App)

ex: Version 3.2.0 or n/a if unknown - V2 is no longer usable or supported

Date/Time Error first noticed?

Users Affected?

Was Error message received?

Error Message Received

Use n/a if not applicable

Error Consistent or Sporadic?

Inbound or Outbound Faxes?

Sender Name

Ex: Dr. Joe Smith or Baptist Hospital

Sender Fax #

Ex: 5554441234 or 0 if unknown

Recipient Name

Ex: Dr. Joe Smith or Baptist Hospital

Recipient Fax #

Ex: 5554441234 or 0 if unknown

Date/Time Fax sent

Time Fax Sent

Fax Page Count

Username/Email Address

Has your EMR been notified of the new branch?

Branch Code

Ex: A01 (n/a if not applicable)

Go-Live Date

Branch Name

Branch Address

Fax Number

Cover Sheet to be used?

Phone Number to show on Cover Sheet

User Access

Will new or existing users need access to the new branch?

What EMR do you use that is experiencing delays?

When did you notice the delay?

Is Direct Connect already setup on your computer?

Patient Merging From

Please provide Patient ID

Patient Merging To (Surviving Patient Record)

Please provide Patient ID

Description

Please enter the details of your request. A member of our support staff will respond as soon as possible. Do not include PHI.

Attachments

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