Patientco Credit Card Device Issues Form

Use this form to report issues with a Patientco credit card device. Submission of this form will automatically create an IS Service Request and be routed to the proper IS resources.
DO NOT include any Protected Health Information (PHI) on this form.

By checking this box, I am verifying that I am an Authorized Requestor in a manager/director role or a designated authorized requestor. *

Verified

Requestor name: *

Requestor position: *

Requestor email: *

Requestor phone number: *

Practice/Location name: *

Has Patientco/Axiom been contacted regarding the issue? *

Please enter a service call with Patientco/Axiom to complete troubleshooting prior to opening a HelpDesk ticket with UH.

Please provide any information available regarding the service call, such as ticket number, representative name, and troubleshooting details:

Credit Card Device Serial Number: *

Workstation/Machine ID (e.g. 0100RGO01001D, FRD7ZG2, 2UA21127Y1): *

Campus/Area: *

Department (e.g. Kentwood, Primary Care GA Avenue, Day Surgery): *

Physical Location (e.g. ED-Pod A, Front Desk, Booth 4): *

Responsible Manager: *

Details of issue: *

Troubleshooting steps already taken: *