Patientco Credit Card Device Request or Replacement Form

Use this form to submit a request for Epic setup of a new or replacement 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 (First and Last): *

Requestor Position: *

Requestor Email Address: *

Requestor Phone Number: *

Practice/Location Name: *

Please choose one of the following: *

Has network connectivity been confirmed, coordinated or installed at the device location (available Ethernet port)? *

Please enter a HelpDesk ticket for IT to evaluate the area for network connectivity prior to submitting this request.

Is an appropriate power receptacle available within 5 feet of device? *

Please enter a HelpDesk ticket for IT to evaluate the area for network connectivity prior to submitting this request.

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: *

Credit Card Device Serial Number (1): *

Workstation/Machine ID (e.g. 0100RGO01001D, FRD7ZG2, 2UA21127Y1)(1): *

Campus/Area (1): *

Department (e.g. Kentwood, Primary Care GA Avenue, Day Surgery)(1): *

Physical Location (e.g. ED-Pod A, Front Desk, Booth 4)(1): *

Responsible Manager (1): *