Atlassian uses cookies to improve your browsing experience, perform analytics and research, and conduct advertising. Accept all cookies to indicate that you agree to our use of cookies on your device. Atlassian cookies and tracking notice, (opens new window)
JIRA is not a HIPAA-compliant platform. Please do not include any Protected Health Information (PHI). Instead, reference the location of the information within the patient chart.
Support
Your Support Hub: EHR, IT & Beyond
Third Party SaaS Customers
EHR Licensing Support
For Third-Party SaaS Customers
Required fields are marked with an asterisk*
{"xsrfToken":"b0d3e78e3853c1888db969c1cb50bc62599cb40a_lout","branding":{"id":"60","key":"nope","name":"Support","portalBaseUrl":"/servicedesk/customer/portal/60","logoUrl":"/rest/servicedesk/1/customer/viewport-resources/portal-logo/60/18","theme":{"headerBGColor":"#ffffff","headerLinkColor":"#292929","headerLinkHoverColor":"#12734b","headerLinkHoverBGColor":"#12734b","headerBadgeColor":"#12734b"}},"helpCenterBranding":{"logoUrl":"https://api.media.atlassian.com/file/654c3118-4351-4ecf-bc05-f1dfd567c9d2/image/cdn?token=eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiJiN2NhY2UzMy0yN2FiLTQyMzctYmMyMy1kMzc0MmJlMjRhMDciLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpmaWxlOjY1NGMzMTE4LTQzNTEtNGVjZi1iYzA1LWYxZGZkNTY3YzlkMiI6WyJyZWFkIl19LCJleHAiOjE3NzYwMTM1NjgsIm5iZiI6MTc3NjAxMjk2OH0.f_r95pcrviFOkhM8Aj3rUcSGr4cQKiH7NvDrhHsEE2g&client=b7cace33-27ab-4237-bc23-d3742be24a07&mode=fit","logoId":"654c3118-4351-4ecf-bc05-f1dfd567c9d2","isLogoAvailable":true,"helpCenterTitle":"Welcome to the Carbon Health Help Center!","sharedPortalName":"Help Center","userInitialAnnouncementHeader":"Support Forms (People, Benefits, and Provider)","userInitialAnnouncementMessageWiki":"<p><a href=\"https://carbonhealthsupport.zendesk.com/hc/en-us\" class=\"external-link\" rel=\"nofollow noreferrer\" target=\"_blank\" style=\"text-decoration: underline;\">https://carbonhealthsupport.zendesk.com/hc/en-us</a></p>","translations":{"en-US":{"helpCenterTitle":"Welcome to the Carbon Health Help Center!","sharedPortalName":"Help Center","announcementHeader":"Support Forms (People, Benefits, and Provider)","announcementMessage":"https://carbonhealthsupport.zendesk.com/hc/en-us","localeDisplayName":"English (United States)"}},"canEditAnnouncement":false,"siteDefaultLanguageTag":"en-US","userLanguageTag":"en-US","portalThemeColor":"#19191b","helpCenterTitleColor":"#ffffff","bannerMediaApiUrl":"https://api.media.atlassian.com/file//image/cdn?token=eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiJiN2NhY2UzMy0yN2FiLTQyMzctYmMyMy1kMzc0MmJlMjRhMDciLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpmaWxlOiI6WyJyZWFkIl19LCJleHAiOjE3NzYwMTM1NjgsIm5iZiI6MTc3NjAxMjk2OH0.7ZClUzFtd-95ehHUQzJN9fDHZmdABnfJY5gbddlcrQ0&client=b7cace33-27ab-4237-bc23-d3742be24a07&height=300&mode=fit","bannerMediaApiFileId":"","useDefaultBanner":false,"isBannerAvailable":true,"hasTopBarBeenSplit":false},"portal":{"id":"60","key":"nope","projectId":10399,"serviceDeskId":60,"name":"Support","description":"<p>Your Support Hub: EHR, IT & Beyond</p>","portalBaseUrl":"/servicedesk/customer/portal/60","reqTypes":[{"id":"3279","name":"Account & Password Troubleshooting","descriptionHtml":"","callToAction":"Account & Password Troubleshooting","introHtml":"<p>Do you have issues logging in? Did you forget your a password? Raise a ticket here if you cannot log in to your device, or you are facing issues logging in to an app or service, or if you need your Apple ID passcode reset.</p>","icon":10504,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10504","groups":[2356],"key":""},{"id":"3277","name":"Apps Access & Permissions Requests","descriptionHtml":"","callToAction":"Apps Access & Permissions Requests","introHtml":"<p>Do you need to have a new access added to your Dashboard, Are you traveling abroad? Here you can raise a ticket to request access to Apps and Services (Google, Okta, Jira, Etc.)and or Travel special permissions</p>","icon":10466,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10466","groups":[2356],"key":""},{"id":"3182","name":"Billing/Insurance","descriptionHtml":"","callToAction":"Billing/Insurance","introHtml":"","icon":10484,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10484","groups":[2290],"key":""},{"id":"3183","name":"Charting Issues","descriptionHtml":"","callToAction":"Charting Issues","introHtml":"","icon":10634,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10634","groups":[2290],"key":""},{"id":"850","name":"EHR Licensing Support","descriptionHtml":"","callToAction":"EHR Licensing Support","introHtml":"<p>For Third-Party SaaS Customers</p>","icon":10511,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10511","groups":[216],"key":""},{"id":"3184","name":"Family Account","descriptionHtml":"","callToAction":"Family Account","introHtml":"","icon":10499,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10499","groups":[2290],"key":""},{"id":"3280","name":"Hardware/Devices Requests and Troubleshooting","descriptionHtml":"","callToAction":"Hardware/Devices Requests and Troubleshooting","introHtml":"<p>Use this option if you need help with physical equipment like computers, monitors, keyboards, mice, printers, or mobile devices. Select this if your device is broken, not working normally, or if you need a new device or accessory.</p>","icon":10608,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10608","groups":[2356],"key":""},{"id":"3185","name":"Lab Issues","descriptionHtml":"<p>JIRA is not a HIPAA complaint platform, please refrain from sharing PHI. Instead, please mention where in the chart the information needed can be found</p>","callToAction":"Lab Issues","introHtml":"","icon":10503,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10503","groups":[2290],"key":""},{"id":"3281","name":"Network Issues","descriptionHtml":"","callToAction":"Network Issues","introHtml":"<p>Choose this option if you are having problems with your internet connection, Wi-Fi, Network Hardware. Use this for any issues related to getting online or accessing network at work.</p>","icon":10474,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10474","groups":[2356],"key":""},{"id":"3186","name":"Patient account","descriptionHtml":"","callToAction":"Patient account","introHtml":"","icon":10493,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10493","groups":[2290],"key":""},{"id":"3187","name":"Prescriptions/RX Issues","descriptionHtml":"","callToAction":"Prescriptions/RX Issues","introHtml":"","icon":10816,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10816","groups":[2290],"key":""},{"id":"3188","name":"Provider app Log in Issues","descriptionHtml":"","callToAction":"Provider app Log in Issues","introHtml":"","icon":10470,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10470","groups":[2290],"key":""},{"id":"3189","name":"Provider App Outage","descriptionHtml":"","callToAction":"Provider App Outage","introHtml":"","icon":10489,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10489","groups":[2290],"key":""},{"id":"3190","name":"Scheduling Issues","descriptionHtml":"","callToAction":"Scheduling Issues","introHtml":"","icon":10488,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10488","groups":[2290],"key":""},{"id":"3282","name":"Software Issues & Troubleshooting","descriptionHtml":"","callToAction":"Software Issues & Troubleshooting","introHtml":"<p>Are you having issues with an app? Is it not working as desired? Do you want to report a problem with a software? Select this option if you have problems to report with software functionalities (Jira, Production Apps, Virtual Machine, Engineering Apps, etc.)</p>","icon":10781,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10781","groups":[2356],"key":""},{"id":"3244","name":"Workplace Health Issues","descriptionHtml":"","callToAction":"Workplace Health Issues","introHtml":"","icon":10485,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10485","groups":[2290],"key":""},{"id":"871","name":"EHR Widget","descriptionHtml":"","callToAction":"EHR Widget","introHtml":"","icon":10511,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10511","groups":[],"key":""},{"id":"828","name":"Email","descriptionHtml":"","callToAction":"Email","introHtml":"","icon":10492,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10492","groups":[],"key":""},{"id":"822","name":"IT Help","descriptionHtml":"","callToAction":"IT Help","introHtml":"","icon":10724,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10724","groups":[],"key":""},{"id":"826","name":"Workplace Health Lead","descriptionHtml":"","callToAction":"Workplace Health Lead","introHtml":"","icon":10485,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10485","groups":[],"key":""}],"reqGroups":[{"id":2290,"name":"Carby OS Support"},{"id":2356,"name":"IT Help Desk"},{"id":216,"name":"Third Party SaaS Customers"}],"orderMapping":{"2356":[3277,3279,3283,3280,3281,3282],"213":[821],"2257":[3046],"2258":[3046],"216":[850],"2290":[3184,3186,3183,3188,3185,3189,3187,3182,3190,3244]},"kbs":{"kbEnabled":false,"serviceDeskId":-1},"createPermission":true,"portalAnnouncement":{"portalId":60,"canEditAnnouncement":false,"canAdministerProject":false,"portalProjectKey":"SUPP","userLanguageHeader":"HIPAA Reminder:","userLanguageMessageWiki":"<p>JIRA is not a HIPAA-compliant platform. Please do not include any Protected Health Information (PHI). Instead, reference the location of the information within the patient chart.</p>","defaultLanguageHeader":"HIPAA Reminder:","defaultLanguageMessage":"JIRA is not a HIPAA-compliant platform. Please do not include any Protected Health Information (PHI). Instead, reference the location of the information within the patient chart.","defaultLanguageDisplayName":"English (United States)","isUsingLanguageSupport":false,"translations":{}},"canViewCreateRequestForm":true,"isProjectSimplified":false,"mediaApiUploadInformation":{"token":"eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiJiN2NhY2UzMy0yN2FiLTQyMzctYmMyMy1kMzc0MmJlMjRhMDciLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTp1cGxvYWQ6KiI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y29sbGVjdGlvbjp1cGxvYWQtdXNlci1jb2xsZWN0aW9uLS03OTYzNzg0MDgiOlsicmVhZCIsImNyZWF0ZSIsInVwZGF0ZSJdLCJ1cm46ZmlsZXN0b3JlOmNodW5rOioiOlsicmVhZCIsImNyZWF0ZSJdfSwiZXhwIjoxNzc2MDE0MTY4LCJuYmYiOjE3NzYwMTI5NjgsImFub25JZCI6ImFub24tdXNlciIsImh0dHBzOi8vaWQuYXRsYXNzaWFuLmNvbS9hcHBBY2NyZWRpdGVkIjpmYWxzZX0.yhHG1PK7pYh-oH3hwHZTolJYh6c2a7DW86k-7SGLKjs","targetCollection":"upload-user-collection--796378408","endpointUrl":"https://api.media.atlassian.com","clientId":"b7cace33-27ab-4237-bc23-d3742be24a07","tokenDurationInMins":20}},"reqCreate":{"id":850,"projectId":10399,"issueType":{"id":"10351","name":"Support"},"form":{"name":"EHR Licensing Support","descriptionHtml":"","callToAction":"EHR Licensing Support","intro":"<p>For Third-Party SaaS Customers</p>","instructions":"","icon":10511,"iconUrl":"https://mdcollab.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10511","key":""},"fields":[{"fieldType":"text","fieldId":"email","fieldConfigId":"","label":"Email confirmation to","description":"","descriptionHtml":"","required":true,"displayed":true,"presetValues":[]},{"fieldType":"text","jiraFieldType":"summary","fieldId":"summary","fieldConfigId":"","label":"Summary","description":"","descriptionHtml":"","required":true,"displayed":false,"presetValues":["(TPS) Thank You for Submitting Request(TPS)"]}],"userOrganisations":[],"canBrowseUsers":true,"requestCreateBaseUrl":"/servicedesk/customer/portal/60/create/850","requestValidateBaseUrl":"/servicedesk/customer/portal/60/validate/850","calendarParams":{"firstDay":0,"date":"2026-04-12T09:56:09-0700","useISO8601WeekNumbers":false,"dateIfFormat":"%e/%b/%y","dateTimeIfFormat":"%e/%b/%y %I:%M %p","timeFormat":"12"},"kbs":{"kbEnabled":false,"serviceDeskId":-1},"canRaiseOnBehalf":false,"canSignupCustomers":false,"canCreateAttachments":true,"attachmentRequiredField":false,"hasGroups":true,"canSubmitWithEmailAddress":true,"showRecaptcha":true,"siteKey":"6LePXLkdAAAAAF4gCNalrL1IvZcqbNbZf_Zakudd","mediaApiUploadInformation":{"token":"eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiJiN2NhY2UzMy0yN2FiLTQyMzctYmMyMy1kMzc0MmJlMjRhMDciLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTp1cGxvYWQ6KiI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y29sbGVjdGlvbjp1cGxvYWQtdXNlci1jb2xsZWN0aW9uLS03OTYzNzg0MDgiOlsicmVhZCIsImNyZWF0ZSIsInVwZGF0ZSJdLCJ1cm46ZmlsZXN0b3JlOmNodW5rOioiOlsicmVhZCIsImNyZWF0ZSJdfSwiZXhwIjoxNzc2MDE0MTY5LCJuYmYiOjE3NzYwMTI5NjksImFub25JZCI6ImFub24tdXNlciIsImh0dHBzOi8vaWQuYXRsYXNzaWFuLmNvbS9hcHBBY2NyZWRpdGVkIjpmYWxzZX0.sF1ue-IYBDgPj4eu3ZTEO0r0KhJFKBob-IGSDPsYNFk","targetCollection":"upload-user-collection--796378408","endpointUrl":"https://api.media.atlassian.com","clientId":"b7cace33-27ab-4237-bc23-d3742be24a07","tokenDurationInMins":20},"hasProformaForm":true,"proformaTemplateForm":{"id":16,"updated":"2025-01-02T21:47:08.116032027Z","publish":{"jira":{"submitOnCreate":true,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[850],"submitOnCreate":true,"validateOnCreate":true}},"design":{"settings":{"templateId":16,"name":"Third Part Support","submit":{"lock":true,"pdf":false},"templateFormUuid":"f662f3a8-3d40-4d77-8f9b-c0498b46a872"},"layout":[{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"info"},"content":[{"type":"paragraph","attrs":{"localId":"fc0d60dd-8e27-421e-b560-990a9a77fc1b"},"content":[{"type":"text","text":"Our Service Desk is not HIPAA compliant as it is not intended to be a recipient or storage for PHI."},{"type":"hardBreak"},{"type":"text","text":"Please do not provide any PHI outside of MRN as an identifier."},{"type":"hardBreak"},{"type":"text","text":"You can utilize communication log or staff messaging for pertinent information."}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":930},"layout":"default","localId":"a6f11f06-1c77-4f88-b1c3-a3114cb5cd86"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":1},"layout":"default","localId":"4b982030-0a1d-4e56-a20e-ee7532e773bd"}}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"info"},"content":[{"type":"paragraph","attrs":{"localId":"11e16ab7-4c7e-4ba1-8de6-a6c447ee3326"},"content":[{"type":"text","text":"For Non-EHR issues or requests please follow your organization’s IT protocols and guidelines."}]}]}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":5},"layout":"default","localId":"5751cf53-2879-404d-8d23-c2d5b9e3dbaf"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":18},"layout":"default","localId":"9b54ee22-d624-4cfc-96e0-ac590ebc6082"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":20},"layout":"default","localId":"2d560f45-9e44-4269-afd8-f2e3b48d2827"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":843},"layout":"default","localId":"002d15a6-8fb2-46ae-b074-b64bedee3ba4"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":22},"layout":"default","localId":"8d98a33a-9627-4aee-86d4-1cad3ece9ba6"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":23},"layout":"default","localId":"5f3feb06-084c-4348-9d13-cbb4c9a38db3"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":24},"layout":"default","localId":"cd18bdb6-039e-4707-83ef-296c17090e76"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":25},"layout":"default","localId":"772e9078-59f3-4597-9917-b0c6a5e383d3"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":26},"layout":"default","localId":"38331df2-b677-4b0b-ab06-a075b59357a2"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":35},"layout":"default","localId":"dfd1d25d-6d43-4a52-8c51-19c52623dc79"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":884},"layout":"default","localId":"b96ea615-b3b0-498f-8d4b-991ffcb31490"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":918},"layout":"default","localId":"cfa6e1dc-2a52-4214-9947-357de39e95c0"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":39},"layout":"default","localId":"6cb2eaec-5210-4e24-87c6-f180b4be0187"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":40},"layout":"default","localId":"16293801-631f-4c42-a7d0-702f27961730"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":41},"layout":"default","localId":"8b8355af-e7de-45ab-9211-229222afb917"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":42},"layout":"default","localId":"11c82c20-3c02-4574-a90c-2352401af6f4"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":907},"layout":"default","localId":"4e0e9f82-e7e9-4751-b613-0bc94409cfe3"}}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"note"},"content":[{"type":"paragraph","attrs":{"localId":"fb7ed796-10c7-4b31-af0f-b1340d1a58df"},"content":[{"type":"text","text":"Please review this video on how to refund patients by clicking on the link provided below. "}]},{"type":"paragraph","attrs":{"localId":"fb7ed796-10c7-4b31-af0f-b1340d1a58df"},"content":[{"type":"text","text":"If you still need assistance, please email your designated billing support team."}]},{"type":"paragraph","attrs":{"localId":"fb7ed796-10c7-4b31-af0f-b1340d1a58df"},"content":[{"type":"hardBreak"},{"type":"inlineCard","attrs":{"url":"https://www.loom.com/share/79879a00c72f48fdb9e96febb244e366?sid=fe27d58c-e904-4f6a-a0d5-5327d681b0eb"}},{"type":"text","text":" "}]}]}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"success"},"content":[{"type":"paragraph","attrs":{"localId":"ed2cb9c6-f7c4-4184-a79f-b272f8bc795d"},"content":[{"type":"text","text":"Please email the billing support team for your request. Include the patients MRN and issue you are having."}]},{"type":"paragraph","attrs":{"localId":"2964894a-243a-40e8-bb54-b0818ca1d908"},"content":[{"type":"text","text":"INCLUDE NO PHI IN THE EMAIL. No other identifying information is needed to be sent through email."}]}]}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":53},"layout":"default","localId":"2a5be01f-6337-42a3-af0a-148b361a37e1"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":886},"layout":"default","localId":"aed33f24-c001-4cdf-a4e8-0569e7754a9c"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":919},"layout":"default","localId":"ebc8dbbf-205f-4ee8-8ffb-05817950c745"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":57},"layout":"default","localId":"22904db5-d387-4a7f-9165-89109917c4ee"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":58},"layout":"default","localId":"1803b13c-8303-4d63-bff9-4c2f31561267"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":59},"layout":"default","localId":"684fb853-3f77-4d5f-acb6-13693376c988"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":60},"layout":"default","localId":"81ebffcf-4a42-4d67-baa8-987aa89d2398"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":908},"layout":"default","localId":"bcedf87d-c43f-4a2b-aebd-5b4e10e09130"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":69},"layout":"default","localId":"b9868f9a-c9da-4cc1-a1e1-e53d2790b6f0"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":920},"layout":"default","localId":"dd28d2f3-72b0-45c2-9591-fecb5b2bfb4e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":76},"layout":"default","localId":"efb61e2c-bff2-4610-83be-77f9a7cebf03"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":77},"layout":"default","localId":"dba00373-cc30-4cb4-b07e-6e67c0a330e2"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":78},"layout":"default","localId":"54404f28-fecb-4577-8b72-b94a2825114e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":79},"layout":"default","localId":"594a8d84-aee6-49e2-91bc-84f1fe94224b"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":80},"layout":"default","localId":"d6f21f9e-9126-4720-8d8c-ff3270237201"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":83},"layout":"default","localId":"ce05a62a-c679-4166-a38e-4f11c9de4470"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":888},"layout":"default","localId":"5c9c8f95-8379-4df7-8b02-58596d9ed662"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":921},"layout":"default","localId":"fe625225-eb8c-4bc0-901f-cf7ce7c04257"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":87},"layout":"default","localId":"9d7b1217-67c5-4412-b740-b314d532fb8b"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":88},"layout":"default","localId":"dd7b0edc-5d8a-472a-90c1-6fc60448cad6"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":90},"layout":"default","localId":"37be6f84-01a9-4ae6-a25d-d2db7b0ad9a6"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":909},"layout":"default","localId":"76fb65d5-a802-428c-9d63-165e116aaf83"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":113},"layout":"default","localId":"6cc8ad5c-aa7f-40f2-a5e9-65fcc731bf9c"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":965},"layout":"default","localId":"0fedc8c1-0525-4edf-ac4f-4bfb70548afc"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":977},"layout":"default","localId":"f0f6c594-5af9-4112-a543-864568b96e7a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":978},"layout":"default","localId":"f5f6d6c2-9473-460e-83a2-24edc198c01d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":979},"layout":"default","localId":"7ab40368-ba1e-4165-82fa-f00bbbf83356"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":981},"layout":"default","localId":"a000151e-d289-4f79-937f-fdd5ae74c64d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":982},"layout":"default","localId":"28fe2c4e-2353-4870-a0bd-691c43c1951d"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":968},"layout":"default","localId":"e48d2086-7d3e-4cda-b47c-331fad3ce93f"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":973},"layout":"default","localId":"99594333-1eab-4484-81ed-7030da3c6b7e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":975},"layout":"default","localId":"76aabb84-a33b-49d3-9ccf-c3ea7bd0bca0"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":976},"layout":"default","localId":"fa0a0104-09d5-41c6-b7c5-bad6d199bb6e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":980},"layout":"default","localId":"f81fc6d3-5b66-4801-8e4e-a3da56467b37"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":969},"layout":"default","localId":"67edd05f-439a-44ed-955b-00e4bbdc5e8b"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":970},"layout":"default","localId":"b98ef3ba-5a34-4e8a-b297-0a701ebfb3f0"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":972},"layout":"default","localId":"251f3214-c5e0-436b-96ba-48089c2379c9"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":984},"layout":"default","localId":"bd255ed0-9b4e-4fae-9c80-1e2522618429"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":963},"layout":"default","localId":"33d01052-660c-4f5b-830f-65a744f46057"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":114},"layout":"default","localId":"03358d68-eb4b-4607-92f4-011d3f9cbade"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":983},"layout":"default","localId":"cc03ce0f-a2fd-4ffd-9560-7411ee8f4985"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":116},"layout":"default","localId":"2c2c5cc7-6bd2-4bb9-8d5b-885e3916f63a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":117},"layout":"default","localId":"72528b82-d278-437d-b2ff-3f92f328258e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":910},"layout":"default","localId":"c45ae0ef-f702-4e5b-977e-9a22cd40a6b2"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":120},"layout":"default","localId":"2b33da63-b674-4060-9559-359666b91bca"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":889},"layout":"default","localId":"731b02fc-f160-42e5-b970-8b16fa5c3be0"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":922},"layout":"default","localId":"b8eb758e-5d0c-43ab-852c-842ed7dda81c"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":124},"layout":"default","localId":"6851d388-cfba-4285-893b-74cb50d116bd"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":868},"layout":"default","localId":"384c641a-1713-4b4d-88b5-29b0c96c2776"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":125},"layout":"default","localId":"b36ae4f0-d24a-437c-8188-df0df8a2358a"}},{"type":"panel","attrs":{"panelType":"info"},"content":[{"type":"paragraph","attrs":{"localId":"6ce40e86-3783-4df4-9bd5-9e4e62e7e33b"},"content":[{"type":"text","text":"Please make sure that the parent’s ID is uploaded into the minor account(s) that want to be added on the Family Account."}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":929},"layout":"default","localId":"f1a16b19-70a3-4b9d-abce-fd5967f74793"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":128},"layout":"default","localId":"72d9e4ad-d192-404e-8669-83c2b7eae180"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":131},"layout":"default","localId":"7c063230-bc46-45f4-b463-141a7c5ea37c"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":923},"layout":"default","localId":"9069e3ee-198f-49cb-ab15-acf680a00342"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":134},"layout":"default","localId":"f5644c47-76ab-4cb6-aeb8-d46e1e0213f6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":135},"layout":"default","localId":"5315bd30-cc3e-42e9-a578-46a2bf82ef58"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":136},"layout":"default","localId":"5fdff6dd-db4b-4f9f-8dae-14a53906c38e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":137},"layout":"default","localId":"78a6850a-0f8e-4c06-9f24-2f6ccc53be84"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":138},"layout":"default","localId":"deee22b0-6109-41f6-ab60-c96a9fdbcec2"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":139},"layout":"default","localId":"1083ea9f-7fcc-42df-ab43-4207e7079c65"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":912},"layout":"default","localId":"77df88c3-79be-4e96-9dfc-63c87c7dc8ed"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":658},"layout":"default","localId":"ca3d1458-7520-4fc2-9c26-9ca946dfd780"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":143},"layout":"default","localId":"35cede63-84ed-4807-bfda-1c3d0dd2ccb7"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":915},"layout":"default","localId":"3588556f-6d32-4195-85c2-278fc8e83a63"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":890},"layout":"default","localId":"f7d37e1d-917c-4b0e-b353-b2a1fe2b0141"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":924},"layout":"default","localId":"de187941-ca0e-44d7-9796-b1a090d45da5"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":147},"layout":"default","localId":"c5ca8f02-f1c1-479a-9ec0-3be181c06035"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":148},"layout":"default","localId":"9f19d586-2726-4a59-b497-5f8d0d41aa25"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":149},"layout":"default","localId":"6863b704-9645-4f9b-bf4e-6d55879dbf40"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":870},"layout":"default","localId":"d3d8c460-4a64-4a62-9ce4-6f79bb8db693"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":871},"layout":"default","localId":"2460baf6-1b14-4843-8d9d-f333b77a2ceb"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":872},"layout":"default","localId":"417226e0-77ca-4059-8189-e19d85b40a68"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":877},"layout":"default","localId":"f67e4316-8a18-474d-b0c8-9abca63fb3ae"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":878},"layout":"default","localId":"6d87b9d2-85e0-4e75-b385-454c239e2ccb"}}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"success"},"content":[{"type":"heading","attrs":{"level":3,"localId":"fc2c2031-d611-4e2e-a9ea-6983a6a356d8"},"content":[{"type":"text","text":"Please enter the state abbreviation in each of the following fields, e.g., CA for California and MI for Michigan."}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":880},"layout":"default","localId":"73d09260-626b-4f5b-b160-4d442300f32f"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":881},"layout":"default","localId":"2cfed5a1-58eb-483e-9ec0-9524a6cf4b85"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":150},"layout":"default","localId":"8231b5e1-d886-4d2d-9c25-ad648b381abf"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":905},"layout":"default","localId":"f8fa1809-8f27-4500-942a-d0715355bb97"}}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"success"},"content":[{"type":"paragraph","attrs":{"localId":"fff30e4f-2248-41bd-aed8-6ad8ed32d4b3"},"content":[{"type":"text","text":"Please press and your request will be automatically completed."},{"type":"hardBreak"},{"type":"text","text":" If you have further questions, please reply to the email you’ll receive with your ticket information. "},{"type":"hardBreak"},{"type":"text","text":"Thank you"}]}]}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"success"},"content":[{"type":"paragraph","attrs":{"localId":"1155a129-aa17-4b30-ba35-e6790c7279c6"},"content":[{"type":"text","text":"Please press Send now and you will receive instructions to your email. If you have further questions please reply to the email you’ll receive with your ticket information. "},{"type":"hardBreak"},{"type":"text","text":"Thank you"}]}]}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":926},"layout":"default","localId":"8aa3f4a1-6f7d-4e53-8d6c-81b480f5fa74"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":925},"layout":"default","localId":"3c2a175e-f7c4-4543-a9fc-d51fe6ae16d4"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":927},"layout":"default","localId":"283d0ec6-f573-47e8-b7ac-a2a3b0d62391"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":172},"layout":"default","localId":"59b482b5-4e38-4598-9de8-088cbb24eae7"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":928},"layout":"default","localId":"98955ad6-a88f-448f-b8b4-eddf6fc20dde"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":913},"layout":"default","localId":"fb44876a-6b1f-4ced-95be-8f26200a6049"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":934},"layout":"default","localId":"f81d6248-faf1-402f-917a-df6c7a86733e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":935},"layout":"default","localId":"6e5da3a6-2309-45ba-8a14-0081a0053618"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":936},"layout":"default","localId":"035f9b8a-b517-43de-8a2c-b41f15d33121"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":937},"layout":"default","localId":"442b0ffa-dc1a-41c2-a8e5-e42dd2233ed7"}},{"type":"paragraph","content":[]}]}],"conditions":{"84":{"i":{"co":{"cIds":{"83":["12997","12998","13000","13001"]}}},"o":{"sIds":["20"]},"t":"sh"},"121":{"i":{"co":{"cIds":{"120":["13029","13030","13031"]}}},"o":{"sIds":["31"]},"t":"sh"},"966":{"i":{"co":{"cIds":{"113":["13070"]}}},"o":{"sIds":["25"]},"t":"sh"},"917":{"i":{"co":{"cIds":{"143":["13023"]}}},"o":{"sIds":["42"]},"t":"sh"},"898":{"i":{"co":{"cIds":{"57":["10885"]}}},"o":{"sIds":["15"]},"t":"sh"},"17":{"i":{"co":{"cIds":{"5":["12944"]}}},"o":{"sIds":["4"]},"t":"sh"},"517":{"i":{"co":{"cIds":{"5":["12951"]}}},"o":{"sIds":["44"]},"t":"sh"},"894":{"i":{"co":{"cIds":{"18":["12963","12964","12965","12966","12981","12968","12969","12970","12971","12972","12973","12974","12975","12976","12977","12978","12979","12982","12980","12967"]}}},"o":{"sIds":["7"]},"t":"sh"},"897":{"i":{"co":{"cIds":{"53":["13017","13019","13020","13018","13021"]}}},"o":{"sIds":["16"]},"t":"sh"},"74":{"i":{"co":{"cIds":{"69":["12990","12992","12991"]}}},"o":{"sIds":["18"]},"t":"sh"},"34":{"i":{"co":{"cIds":{"5":["12943"]}}},"o":{"sIds":["8"]},"t":"sh"},"874":{"i":{"co":{"cIds":{"143":["13027","13024","13025","13026","13028"]}}},"o":{"sIds":["38"]},"t":"sh"},"142":{"i":{"co":{"cIds":{"5":["12948"]}}},"o":{"sIds":["34"]},"t":"sh"},"89":{"i":{"co":{"cIds":{"83":["13000"]}}},"o":{"sIds":["21"]},"t":"sh"},"51":{"i":{"co":{"cIds":{"35":["12957"]}}},"o":{"sIds":["11"]},"t":"sh"},"19":{"i":{"co":{"cIds":{"18":["12963","12964","12966","12965","12981","12968","12969","12970","12971","12972","12973","12974","12975","12976","12977","12978","12979","12982","12980","12967"]}}},"o":{"sIds":["5"]},"t":"sh"},"896":{"i":{"co":{"cIds":{"53":["13017","13018","13021"]}}},"o":{"sIds":["14"]},"t":"sh"},"504":{"i":{"co":{"cIds":{"1":["12941"]}}},"o":{"sIds":["3"]},"t":"sh"},"931":{"i":{"co":{"cIds":{"930":["1"]}}},"o":{"sIds":["1"]},"t":"sh"},"914":{"i":{"co":{"cIds":{"143":["13023"]}}},"o":{"sIds":["35"]},"t":"sh"},"962":{"i":{"co":{"cIds":{"113":["12996"]}}},"o":{"sIds":["28"]},"t":"sh"},"895":{"i":{"co":{"cIds":{"35":["12954"]}}},"o":{"sIds":["10"]},"t":"sh"},"68":{"i":{"co":{"cIds":{"5":["12949"]}}},"o":{"sIds":["17"]},"t":"sh"},"873":{"i":{"co":{"cIds":{"147":["10885"]}}},"o":{"sIds":["37"]},"t":"sh"},"112":{"i":{"co":{"cIds":{"83":["12999"]}}},"o":{"sIds":["23"]},"t":"sh"},"159":{"i":{"co":{"cIds":{"143":["13026"]}}},"o":{"sIds":["43"]},"t":"sh"},"932":{"i":{"co":{"cIds":{"926":["13036","13035","13034","13037"]}}},"o":{"sIds":["45"]},"t":"sh"},"144":{"i":{"co":{"cIds":{"143":["13027","13024","13025","13026","13028"]}}},"o":{"sIds":["36"]},"t":"sh"},"967":{"i":{"co":{"cIds":{"113":["13071"]}}},"o":{"sIds":["26"]},"t":"sh"},"54":{"i":{"co":{"cIds":{"53":["13017","13019","13020","13018","13021"]}}},"o":{"sIds":["13"]},"t":"sh"},"127":{"i":{"co":{"cIds":{"5":["12950"]}}},"o":{"sIds":["32"]},"t":"sh"},"36":{"i":{"co":{"cIds":{"35":["12958","12953","12956"]}}},"o":{"sIds":["9"]},"t":"sh"},"82":{"i":{"co":{"cIds":{"5":["12947"]}}},"o":{"sIds":["19"]},"t":"sh"},"876":{"i":{"co":{"cIds":{"143":["13027","13024","13025","13026","13028"]}}},"o":{"sIds":["41"]},"t":"sh"},"879":{"i":{"co":{"cIds":{"878":["13005"]}}},"o":{"sIds":["40"]},"t":"sh"},"961":{"i":{"co":{"cIds":{"113":["12994","13068"]}}},"o":{"sIds":["29"]},"t":"sh"},"933":{"i":{"co":{"cIds":{"926":["13061","13062","13067"]}}},"o":{"sIds":["46"]},"t":"sh"},"130":{"i":{"co":{"cIds":{"128":["12983","12985","12984","12986","12987","12988","12989"]}}},"o":{"sIds":["33"]},"t":"sh"},"875":{"i":{"co":{"cIds":{"143":["13027"]}}},"o":{"sIds":["39"]},"t":"sh"},"893":{"i":{"co":{"cIds":{"22":["10885"]}}},"o":{"sIds":["6"]},"t":"sh"},"971":{"i":{"co":{"cIds":{"970":["1"]}}},"o":{"sIds":["27"]},"t":"sh"},"91":{"i":{"co":{"cIds":{"83":["12997","12998","13000","13001"]}}},"o":{"sIds":["22"]},"t":"sh"},"52":{"i":{"co":{"cIds":{"5":["12946"]}}},"o":{"sIds":["12"]},"t":"sh"},"960":{"i":{"co":{"cIds":{"1":["12942"]}}},"o":{"sIds":["2"]},"t":"sh"},"119":{"i":{"co":{"cIds":{"5":["12945"]}}},"o":{"sIds":["30"]},"t":"sh"},"964":{"i":{"co":{"cIds":{"113":["13069"]}}},"o":{"sIds":["24"]},"t":"sh"}},"sections":{"12":{"name":"Lab Issues","conditions":["52","504","931"]},"8":{"name":"Billing/Insurance Issues","conditions":["34","504","931"]},"22":{"name":"Patient Account Help(Mirror Form 2)","conditions":["91","82","504","931"]},"5":{"name":"Charting Issue","conditions":["19","17","504","931"]},"10":{"name":"Refund Assistance Needed","conditions":["895","34","504","931"]},"21":{"name":"Un-Merge Account","conditions":["89","82","504","931"]},"43":{"name":"Unknown Prescription Refill Request","conditions":["159","142","504","931"]},"32":{"name":"Provider App Outage","conditions":["127","504","931"]},"31":{"name":"Family Account","conditions":["121","119","504","931"]},"42":{"name":"In House","conditions":["917","142","504","931"]},"18":{"name":"Form 3","conditions":["74","68","504","931"]},"3":{"name":"Yes Provider App","conditions":["504","931"]},"28":{"name":"Not Listed","conditions":["962","112","82","504","931"]},"45":{"conditions":["932","517","504","931"]},"34":{"name":"Prescription/RX Issue","conditions":["142","504","931"]},"19":{"name":"Patient Account Help","conditions":["82","504","931"]},"23":{"name":"Occupational Health/Employer Paid Services","conditions":["112","82","504","931"]},"4":{"name":"Charting Error","conditions":["17","504","931"]},"40":{"name":"Different State","conditions":["879","875","142","504","931"]},"15":{"name":"iPad","conditions":["898","896","52","504","931"]},"11":{"name":"Unable to adjust self-pay","conditions":["51","34","504","931"]},"9":{"name":"Billing/Insurance","conditions":["36","34","504","931"]},"44":{"name":"Scheduling Issues","conditions":["517","504","931"]},"33":{"name":"Provider App Outage Form","conditions":["130","127","504","931"]},"26":{"name":"Deactivate/Reactivate Org","conditions":["967","112","82","504","931"]},"37":{"name":"iPad App","conditions":["873","144","142","504","931"]},"13":{"name":"Lab Issues","conditions":["54","52","504","931"]},"46":{"conditions":["933","517","504","931"]},"24":{"name":"Add New Org","conditions":["964","112","82","504","931"]},"35":{"name":"In House","conditions":["914","142","504","931"]},"16":{"conditions":["897","52","504","931"]},"6":{"name":"iPad","conditions":["893","19","17","504","931"]},"36":{"name":"Prescription/RX Issues","conditions":["144","142","504","931"]},"1":{"conditions":["931"]},"39":{"name":"Ayva/Bravado Issue","conditions":["875","142","504","931"]},"17":{"name":"Provider App Log In Issues","conditions":["68","504","931"]},"25":{"name":"Update Org Admin","conditions":["966","112","82","504","931"]},"14":{"name":"Lab Issue Device","conditions":["896","52","504","931"]},"20":{"name":"Patient Account Help(Mirror Form 2)","conditions":["84","82","504","931"]},"27":{"name":"Reactivate","conditions":["971","967","112","82","504","931"]},"2":{"conditions":["960","931"]},"38":{"name":"Prescription/RX Issues Pt 2","conditions":["874","142","504","931"]},"30":{"name":"Family Account","conditions":["119","504","931"]},"7":{"conditions":["894","17","504","931"]},"29":{"name":"Org Patient","conditions":["961","112","82","504","931"]},"41":{"name":"Prescription/RX Issues Pt 3","conditions":["876","142","504","931"]}},"questions":{"22":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"976":{"type":"tl","label":"Admin Phone Number","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"977":{"type":"tl","label":"Admin Name","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"113":{"type":"cs","label":"Assistance Help Needed","description":"","validation":{"rq":true},"jiraField":"customfield_11163","questionKey":""},"120":{"type":"cs","label":"Family Account","description":"","validation":{"rq":true},"jiraField":"customfield_11179","questionKey":""},"147":{"type":"cm","label":"Device Used","description":"","validation":{"rq":false},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"963":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"925":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"124":{"type":"ts","label":"MRN of Primary Account","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"981":{"type":"rt","label":"Organization Address","description":"Street - Suite/Unit - City - State Abbreviation - Zip Code","validation":{"rq":true},"choices":[],"questionKey":""},"78":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"881":{"type":"ts","label":"Provider's Prescribing State","description":"","validation":{"rq":true,"mnc":2,"mxc":2},"jiraField":"customfield_11172","questionKey":""},"918":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"23":{"type":"ts","label":"if iPad App, what version is being used","description":"How to Find Version History Hyperlink","validation":{"rq":true},"choices":[],"questionKey":""},"929":{"type":"cd","label":"Urgency ","description":"If your request is critical, please select in dropdown.","validation":{"rq":false},"choices":[{"id":"10892","label":"Critical (>5 Mins)"},{"id":"10894","label":"Not Urgent (2-4 Days)"}],"defaultAnswer":{"choices":["10894"]},"questionKey":""},"135":{"type":"ts","label":"if iPad App, what version is being used","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"128":{"type":"cs","label":"Provider App Outage","description":"","validation":{"rq":true},"jiraField":"customfield_11161","questionKey":""},"88":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"77":{"type":"ts","label":"Employee Email who needs Assistance","description":"","validation":{"rq":true,"rgx":{"p":"","m":"Please enter valid Carbon Health Email"}},"choices":[],"defaultAnswer":{"text":""},"questionKey":""},"40":{"type":"ts","label":"if iPad App, what version is being used","description":"How to Find Version History Hyperlink","validation":{"rq":true},"choices":[],"questionKey":""},"920":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"90":{"type":"pg","label":"Case(s) To Be Moved","description":"Write Out Which Cases Belong To Which Patient.","validation":{"rq":true},"choices":[],"questionKey":""},"139":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"870":{"type":"da","label":"What is Date of Service","description":"","validation":{"rq":true},"jiraField":"customfield_11165","questionKey":""},"117":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"908":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"919":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"936":{"type":"tl","label":"Email of Employee Who Needs Access","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"26":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"jiraField":"customfield_11168","defaultAnswer":{"choices":["13002"]},"questionKey":""},"843":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"jiraField":"customfield_11158","questionKey":""},"907":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"134":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"884":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"928":{"type":"tl","label":"Other Information","description":"","validation":{"rq":false},"jiraField":"customfield_11183","questionKey":""},"877":{"type":"rt","label":"What Pharmacy Should the Prescription be Sent to?","description":"Name and Address","validation":{"rq":true},"jiraField":"customfield_11169","questionKey":""},"973":{"type":"tl","label":"Admin Name","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"24":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"jiraField":"customfield_11159","questionKey":""},"888":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"83":{"type":"cs","label":"Patient Account Help","description":"","validation":{"rq":true},"jiraField":"customfield_11164","questionKey":""},"970":{"type":"cs","label":"Action Needed","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Reactivate","other":false},{"id":"2","label":"Deactivate","other":false}],"questionKey":""},"35":{"type":"cs","label":"Billing/Insurance Issues","description":"","validation":{"rq":true},"jiraField":"customfield_11156","questionKey":""},"79":{"type":"ts","label":"if iPad App, what version is being used","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"5":{"type":"cs","label":"Support Needed","description":"What is the issue you are having","validation":{"rq":true},"jiraField":"customfield_11155","questionKey":""},"980":{"type":"tl","label":"Admin Fax Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"59":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"87":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"913":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"890":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"116":{"type":"ts","label":"Clinic Location","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"984":{"type":"tl","label":"Organization name","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"76":{"type":"ts","label":"Employee Name who needs Assistance","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"909":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"138":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"978":{"type":"tl","label":"Admin Email","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"148":{"type":"ts","label":"What App version is being used on iPad","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"889":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"910":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"57":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"935":{"type":"tl","label":"Name of Employee Who Needs Access","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"924":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"921":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"80":{"type":"pg","label":"Description of Issue","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"137":{"type":"cs","label":"Is this happening on a single patient's chart or ALL patient charts","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Single Patient","other":false},{"id":"2","label":"Any/All Charts","other":false}],"questionKey":""},"923":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"979":{"type":"tl","label":"Admin Fax Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"968":{"type":"tl","label":"Organization name","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"1":{"type":"cs","label":"Is This a Provider App Issue?","description":"","validation":{"rq":true},"jiraField":"customfield_11154","questionKey":""},"39":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"878":{"type":"cs","label":"Are the Provider and Pharmacy Located in the Same State?","description":"","validation":{"rq":false},"jiraField":"customfield_11170","questionKey":""},"912":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"25":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"60":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"658":{"type":"at","label":"Screenshot of Issue","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"872":{"type":"tl","label":"Who is the Prescribing Provider","description":"","validation":{"rq":true},"jiraField":"customfield_11167","questionKey":""},"983":{"type":"tl","label":"Organization Name That Patient Belongs To?","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"69":{"type":"cs","label":"Provider App Log In Issues","description":"","validation":{"rq":true},"jiraField":"customfield_11162","questionKey":""},"934":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"58":{"type":"ts","label":"if iPad App, what version is being used","description":"How to Find Version History Hyperlink","validation":{"rq":true},"choices":[],"questionKey":""},"53":{"type":"cs","label":"Lab Issues","description":"","validation":{"rq":true},"jiraField":"customfield_11176","questionKey":""},"42":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"972":{"type":"cs","label":"Is this a Legacy Organization?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Yes","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"880":{"type":"ts","label":"Pharmacy's Location","description":"","validation":{"rq":true,"mnc":2,"mxc":2},"jiraField":"customfield_11171","questionKey":""},"149":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"20":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"jiraField":"customfield_11174","questionKey":""},"965":{"type":"tl","label":"Organization name","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"927":{"type":"tl","label":"Which pseudo provider/staff account is the availability for? (e.g. Berkley Provider UC) ","description":"","validation":{"rq":true},"jiraField":"customfield_11182","questionKey":""},"937":{"type":"cs","label":"Job Title of Employee Who Needs Access","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Clinic Manager","other":false},{"id":"2","label":"Director","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"922":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"871":{"type":"tl","label":"Which Medication","description":"","validation":{"rq":true},"jiraField":"customfield_11166","questionKey":""},"969":{"type":"tl","label":"Organization name","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"886":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"125":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"18":{"type":"cs","label":"Charting Issue","description":"","validation":{"rq":true},"jiraField":"customfield_11160","questionKey":""},"143":{"type":"cs","label":"Prescription/RX Issue","description":"","validation":{"rq":true},"jiraField":"customfield_11178","questionKey":""},"114":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"982":{"type":"rt","label":"Are there any services that differ in price from the generic fee schedule?","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"41":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"905":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["10894"]},"questionKey":""},"150":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"868":{"type":"rt","label":"MRN(s) of Patient(s) to Add/Remove","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"172":{"type":"pg","label":"Please outline the steps you have implemented and any schedule adjustments you are making.","description":"","validation":{"rq":true},"jiraField":"customfield_11184","questionKey":""},"930":{"type":"cs","label":"Do you understand?","description":"","validation":{"rq":true,"ch":"1"},"choices":[{"id":"1","label":"Yes","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"915":{"type":"tl","label":"Clinic Name (find me)","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"131":{"type":"cs","label":"Are other websites on your device loading?","description":"","validation":{"rq":true},"jiraField":"customfield_11180","questionKey":""},"926":{"type":"cs","label":"Scheduling Issue","description":"","validation":{"rq":false},"jiraField":"customfield_11181","questionKey":""},"975":{"type":"tl","label":"Admin Email","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"136":{"type":"cs","label":"Is this happening only for you or everyone at your clinic?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Just Myself","other":false},{"id":"2","label":"Entire Clinic","other":false}],"questionKey":""}}},"uuid":"f662f3a8-3d40-4d77-8f9b-c0498b46a872"},"proforma":{"formExists":true,"formValid":true,"formTemplateData":{"id":16,"updated":"2025-01-02T21:47:08.116032027Z","publish":{"jira":{"submitOnCreate":true,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[850],"submitOnCreate":true,"validateOnCreate":true}},"design":{"settings":{"templateId":16,"name":"Third Part Support","submit":{"lock":true,"pdf":false},"templateFormUuid":"f662f3a8-3d40-4d77-8f9b-c0498b46a872"},"layout":[{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"info"},"content":[{"type":"paragraph","attrs":{"localId":"fc0d60dd-8e27-421e-b560-990a9a77fc1b"},"content":[{"type":"text","text":"Our Service Desk is not HIPAA compliant as it is not intended to be a recipient or storage for PHI."},{"type":"hardBreak"},{"type":"text","text":"Please do not provide any PHI outside of MRN as an identifier."},{"type":"hardBreak"},{"type":"text","text":"You can utilize communication log or staff messaging for pertinent information."}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":930},"layout":"default","localId":"a6f11f06-1c77-4f88-b1c3-a3114cb5cd86"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":1},"layout":"default","localId":"4b982030-0a1d-4e56-a20e-ee7532e773bd"}}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"info"},"content":[{"type":"paragraph","attrs":{"localId":"11e16ab7-4c7e-4ba1-8de6-a6c447ee3326"},"content":[{"type":"text","text":"For Non-EHR issues or requests please follow your organization’s IT protocols and guidelines."}]}]}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":5},"layout":"default","localId":"5751cf53-2879-404d-8d23-c2d5b9e3dbaf"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":18},"layout":"default","localId":"9b54ee22-d624-4cfc-96e0-ac590ebc6082"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":20},"layout":"default","localId":"2d560f45-9e44-4269-afd8-f2e3b48d2827"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":843},"layout":"default","localId":"002d15a6-8fb2-46ae-b074-b64bedee3ba4"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":22},"layout":"default","localId":"8d98a33a-9627-4aee-86d4-1cad3ece9ba6"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":23},"layout":"default","localId":"5f3feb06-084c-4348-9d13-cbb4c9a38db3"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":24},"layout":"default","localId":"cd18bdb6-039e-4707-83ef-296c17090e76"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":25},"layout":"default","localId":"772e9078-59f3-4597-9917-b0c6a5e383d3"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":26},"layout":"default","localId":"38331df2-b677-4b0b-ab06-a075b59357a2"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":35},"layout":"default","localId":"dfd1d25d-6d43-4a52-8c51-19c52623dc79"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":884},"layout":"default","localId":"b96ea615-b3b0-498f-8d4b-991ffcb31490"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":918},"layout":"default","localId":"cfa6e1dc-2a52-4214-9947-357de39e95c0"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":39},"layout":"default","localId":"6cb2eaec-5210-4e24-87c6-f180b4be0187"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":40},"layout":"default","localId":"16293801-631f-4c42-a7d0-702f27961730"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":41},"layout":"default","localId":"8b8355af-e7de-45ab-9211-229222afb917"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":42},"layout":"default","localId":"11c82c20-3c02-4574-a90c-2352401af6f4"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":907},"layout":"default","localId":"4e0e9f82-e7e9-4751-b613-0bc94409cfe3"}}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"note"},"content":[{"type":"paragraph","attrs":{"localId":"fb7ed796-10c7-4b31-af0f-b1340d1a58df"},"content":[{"type":"text","text":"Please review this video on how to refund patients by clicking on the link provided below. "}]},{"type":"paragraph","attrs":{"localId":"fb7ed796-10c7-4b31-af0f-b1340d1a58df"},"content":[{"type":"text","text":"If you still need assistance, please email your designated billing support team."}]},{"type":"paragraph","attrs":{"localId":"fb7ed796-10c7-4b31-af0f-b1340d1a58df"},"content":[{"type":"hardBreak"},{"type":"inlineCard","attrs":{"url":"https://www.loom.com/share/79879a00c72f48fdb9e96febb244e366?sid=fe27d58c-e904-4f6a-a0d5-5327d681b0eb"}},{"type":"text","text":" "}]}]}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"success"},"content":[{"type":"paragraph","attrs":{"localId":"ed2cb9c6-f7c4-4184-a79f-b272f8bc795d"},"content":[{"type":"text","text":"Please email the billing support team for your request. Include the patients MRN and issue you are having."}]},{"type":"paragraph","attrs":{"localId":"2964894a-243a-40e8-bb54-b0818ca1d908"},"content":[{"type":"text","text":"INCLUDE NO PHI IN THE EMAIL. No other identifying information is needed to be sent through email."}]}]}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":53},"layout":"default","localId":"2a5be01f-6337-42a3-af0a-148b361a37e1"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":886},"layout":"default","localId":"aed33f24-c001-4cdf-a4e8-0569e7754a9c"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":919},"layout":"default","localId":"ebc8dbbf-205f-4ee8-8ffb-05817950c745"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":57},"layout":"default","localId":"22904db5-d387-4a7f-9165-89109917c4ee"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":58},"layout":"default","localId":"1803b13c-8303-4d63-bff9-4c2f31561267"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":59},"layout":"default","localId":"684fb853-3f77-4d5f-acb6-13693376c988"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":60},"layout":"default","localId":"81ebffcf-4a42-4d67-baa8-987aa89d2398"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":908},"layout":"default","localId":"bcedf87d-c43f-4a2b-aebd-5b4e10e09130"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":69},"layout":"default","localId":"b9868f9a-c9da-4cc1-a1e1-e53d2790b6f0"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":920},"layout":"default","localId":"dd28d2f3-72b0-45c2-9591-fecb5b2bfb4e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":76},"layout":"default","localId":"efb61e2c-bff2-4610-83be-77f9a7cebf03"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":77},"layout":"default","localId":"dba00373-cc30-4cb4-b07e-6e67c0a330e2"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":78},"layout":"default","localId":"54404f28-fecb-4577-8b72-b94a2825114e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":79},"layout":"default","localId":"594a8d84-aee6-49e2-91bc-84f1fe94224b"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":80},"layout":"default","localId":"d6f21f9e-9126-4720-8d8c-ff3270237201"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":83},"layout":"default","localId":"ce05a62a-c679-4166-a38e-4f11c9de4470"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":888},"layout":"default","localId":"5c9c8f95-8379-4df7-8b02-58596d9ed662"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":921},"layout":"default","localId":"fe625225-eb8c-4bc0-901f-cf7ce7c04257"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":87},"layout":"default","localId":"9d7b1217-67c5-4412-b740-b314d532fb8b"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":88},"layout":"default","localId":"dd7b0edc-5d8a-472a-90c1-6fc60448cad6"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":90},"layout":"default","localId":"37be6f84-01a9-4ae6-a25d-d2db7b0ad9a6"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":909},"layout":"default","localId":"76fb65d5-a802-428c-9d63-165e116aaf83"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":113},"layout":"default","localId":"6cc8ad5c-aa7f-40f2-a5e9-65fcc731bf9c"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":965},"layout":"default","localId":"0fedc8c1-0525-4edf-ac4f-4bfb70548afc"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":977},"layout":"default","localId":"f0f6c594-5af9-4112-a543-864568b96e7a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":978},"layout":"default","localId":"f5f6d6c2-9473-460e-83a2-24edc198c01d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":979},"layout":"default","localId":"7ab40368-ba1e-4165-82fa-f00bbbf83356"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":981},"layout":"default","localId":"a000151e-d289-4f79-937f-fdd5ae74c64d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":982},"layout":"default","localId":"28fe2c4e-2353-4870-a0bd-691c43c1951d"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":968},"layout":"default","localId":"e48d2086-7d3e-4cda-b47c-331fad3ce93f"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":973},"layout":"default","localId":"99594333-1eab-4484-81ed-7030da3c6b7e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":975},"layout":"default","localId":"76aabb84-a33b-49d3-9ccf-c3ea7bd0bca0"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":976},"layout":"default","localId":"fa0a0104-09d5-41c6-b7c5-bad6d199bb6e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":980},"layout":"default","localId":"f81fc6d3-5b66-4801-8e4e-a3da56467b37"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":969},"layout":"default","localId":"67edd05f-439a-44ed-955b-00e4bbdc5e8b"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":970},"layout":"default","localId":"b98ef3ba-5a34-4e8a-b297-0a701ebfb3f0"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":972},"layout":"default","localId":"251f3214-c5e0-436b-96ba-48089c2379c9"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":984},"layout":"default","localId":"bd255ed0-9b4e-4fae-9c80-1e2522618429"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":963},"layout":"default","localId":"33d01052-660c-4f5b-830f-65a744f46057"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":114},"layout":"default","localId":"03358d68-eb4b-4607-92f4-011d3f9cbade"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":983},"layout":"default","localId":"cc03ce0f-a2fd-4ffd-9560-7411ee8f4985"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":116},"layout":"default","localId":"2c2c5cc7-6bd2-4bb9-8d5b-885e3916f63a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":117},"layout":"default","localId":"72528b82-d278-437d-b2ff-3f92f328258e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":910},"layout":"default","localId":"c45ae0ef-f702-4e5b-977e-9a22cd40a6b2"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":120},"layout":"default","localId":"2b33da63-b674-4060-9559-359666b91bca"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":889},"layout":"default","localId":"731b02fc-f160-42e5-b970-8b16fa5c3be0"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":922},"layout":"default","localId":"b8eb758e-5d0c-43ab-852c-842ed7dda81c"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":124},"layout":"default","localId":"6851d388-cfba-4285-893b-74cb50d116bd"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":868},"layout":"default","localId":"384c641a-1713-4b4d-88b5-29b0c96c2776"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":125},"layout":"default","localId":"b36ae4f0-d24a-437c-8188-df0df8a2358a"}},{"type":"panel","attrs":{"panelType":"info"},"content":[{"type":"paragraph","attrs":{"localId":"6ce40e86-3783-4df4-9bd5-9e4e62e7e33b"},"content":[{"type":"text","text":"Please make sure that the parent’s ID is uploaded into the minor account(s) that want to be added on the Family Account."}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":929},"layout":"default","localId":"f1a16b19-70a3-4b9d-abce-fd5967f74793"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":128},"layout":"default","localId":"72d9e4ad-d192-404e-8669-83c2b7eae180"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":131},"layout":"default","localId":"7c063230-bc46-45f4-b463-141a7c5ea37c"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":923},"layout":"default","localId":"9069e3ee-198f-49cb-ab15-acf680a00342"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":134},"layout":"default","localId":"f5644c47-76ab-4cb6-aeb8-d46e1e0213f6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":135},"layout":"default","localId":"5315bd30-cc3e-42e9-a578-46a2bf82ef58"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":136},"layout":"default","localId":"5fdff6dd-db4b-4f9f-8dae-14a53906c38e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":137},"layout":"default","localId":"78a6850a-0f8e-4c06-9f24-2f6ccc53be84"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":138},"layout":"default","localId":"deee22b0-6109-41f6-ab60-c96a9fdbcec2"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":139},"layout":"default","localId":"1083ea9f-7fcc-42df-ab43-4207e7079c65"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":912},"layout":"default","localId":"77df88c3-79be-4e96-9dfc-63c87c7dc8ed"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":658},"layout":"default","localId":"ca3d1458-7520-4fc2-9c26-9ca946dfd780"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":143},"layout":"default","localId":"35cede63-84ed-4807-bfda-1c3d0dd2ccb7"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":915},"layout":"default","localId":"3588556f-6d32-4195-85c2-278fc8e83a63"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":890},"layout":"default","localId":"f7d37e1d-917c-4b0e-b353-b2a1fe2b0141"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":924},"layout":"default","localId":"de187941-ca0e-44d7-9796-b1a090d45da5"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":147},"layout":"default","localId":"c5ca8f02-f1c1-479a-9ec0-3be181c06035"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":148},"layout":"default","localId":"9f19d586-2726-4a59-b497-5f8d0d41aa25"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":149},"layout":"default","localId":"6863b704-9645-4f9b-bf4e-6d55879dbf40"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":870},"layout":"default","localId":"d3d8c460-4a64-4a62-9ce4-6f79bb8db693"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":871},"layout":"default","localId":"2460baf6-1b14-4843-8d9d-f333b77a2ceb"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":872},"layout":"default","localId":"417226e0-77ca-4059-8189-e19d85b40a68"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":877},"layout":"default","localId":"f67e4316-8a18-474d-b0c8-9abca63fb3ae"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":878},"layout":"default","localId":"6d87b9d2-85e0-4e75-b385-454c239e2ccb"}}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"success"},"content":[{"type":"heading","attrs":{"level":3,"localId":"fc2c2031-d611-4e2e-a9ea-6983a6a356d8"},"content":[{"type":"text","text":"Please enter the state abbreviation in each of the following fields, e.g., CA for California and MI for Michigan."}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":880},"layout":"default","localId":"73d09260-626b-4f5b-b160-4d442300f32f"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":881},"layout":"default","localId":"2cfed5a1-58eb-483e-9ec0-9524a6cf4b85"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":150},"layout":"default","localId":"8231b5e1-d886-4d2d-9c25-ad648b381abf"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":905},"layout":"default","localId":"f8fa1809-8f27-4500-942a-d0715355bb97"}}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"success"},"content":[{"type":"paragraph","attrs":{"localId":"fff30e4f-2248-41bd-aed8-6ad8ed32d4b3"},"content":[{"type":"text","text":"Please press and your request will be automatically completed."},{"type":"hardBreak"},{"type":"text","text":" If you have further questions, please reply to the email you’ll receive with your ticket information. "},{"type":"hardBreak"},{"type":"text","text":"Thank you"}]}]}]},{"version":1,"type":"doc","content":[{"type":"panel","attrs":{"panelType":"success"},"content":[{"type":"paragraph","attrs":{"localId":"1155a129-aa17-4b30-ba35-e6790c7279c6"},"content":[{"type":"text","text":"Please press Send now and you will receive instructions to your email. If you have further questions please reply to the email you’ll receive with your ticket information. "},{"type":"hardBreak"},{"type":"text","text":"Thank you"}]}]}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":926},"layout":"default","localId":"8aa3f4a1-6f7d-4e53-8d6c-81b480f5fa74"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":925},"layout":"default","localId":"3c2a175e-f7c4-4543-a9fc-d51fe6ae16d4"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":927},"layout":"default","localId":"283d0ec6-f573-47e8-b7ac-a2a3b0d62391"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":172},"layout":"default","localId":"59b482b5-4e38-4598-9de8-088cbb24eae7"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":928},"layout":"default","localId":"98955ad6-a88f-448f-b8b4-eddf6fc20dde"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":913},"layout":"default","localId":"fb44876a-6b1f-4ced-95be-8f26200a6049"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":934},"layout":"default","localId":"f81d6248-faf1-402f-917a-df6c7a86733e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":935},"layout":"default","localId":"6e5da3a6-2309-45ba-8a14-0081a0053618"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":936},"layout":"default","localId":"035f9b8a-b517-43de-8a2c-b41f15d33121"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":937},"layout":"default","localId":"442b0ffa-dc1a-41c2-a8e5-e42dd2233ed7"}},{"type":"paragraph","content":[]}]}],"conditions":{"84":{"i":{"co":{"cIds":{"83":["12997","12998","13000","13001"]}}},"o":{"sIds":["20"]},"t":"sh"},"121":{"i":{"co":{"cIds":{"120":["13029","13030","13031"]}}},"o":{"sIds":["31"]},"t":"sh"},"966":{"i":{"co":{"cIds":{"113":["13070"]}}},"o":{"sIds":["25"]},"t":"sh"},"917":{"i":{"co":{"cIds":{"143":["13023"]}}},"o":{"sIds":["42"]},"t":"sh"},"898":{"i":{"co":{"cIds":{"57":["10885"]}}},"o":{"sIds":["15"]},"t":"sh"},"17":{"i":{"co":{"cIds":{"5":["12944"]}}},"o":{"sIds":["4"]},"t":"sh"},"517":{"i":{"co":{"cIds":{"5":["12951"]}}},"o":{"sIds":["44"]},"t":"sh"},"894":{"i":{"co":{"cIds":{"18":["12963","12964","12965","12966","12981","12968","12969","12970","12971","12972","12973","12974","12975","12976","12977","12978","12979","12982","12980","12967"]}}},"o":{"sIds":["7"]},"t":"sh"},"897":{"i":{"co":{"cIds":{"53":["13017","13019","13020","13018","13021"]}}},"o":{"sIds":["16"]},"t":"sh"},"74":{"i":{"co":{"cIds":{"69":["12990","12992","12991"]}}},"o":{"sIds":["18"]},"t":"sh"},"34":{"i":{"co":{"cIds":{"5":["12943"]}}},"o":{"sIds":["8"]},"t":"sh"},"874":{"i":{"co":{"cIds":{"143":["13027","13024","13025","13026","13028"]}}},"o":{"sIds":["38"]},"t":"sh"},"142":{"i":{"co":{"cIds":{"5":["12948"]}}},"o":{"sIds":["34"]},"t":"sh"},"89":{"i":{"co":{"cIds":{"83":["13000"]}}},"o":{"sIds":["21"]},"t":"sh"},"51":{"i":{"co":{"cIds":{"35":["12957"]}}},"o":{"sIds":["11"]},"t":"sh"},"19":{"i":{"co":{"cIds":{"18":["12963","12964","12966","12965","12981","12968","12969","12970","12971","12972","12973","12974","12975","12976","12977","12978","12979","12982","12980","12967"]}}},"o":{"sIds":["5"]},"t":"sh"},"896":{"i":{"co":{"cIds":{"53":["13017","13018","13021"]}}},"o":{"sIds":["14"]},"t":"sh"},"504":{"i":{"co":{"cIds":{"1":["12941"]}}},"o":{"sIds":["3"]},"t":"sh"},"931":{"i":{"co":{"cIds":{"930":["1"]}}},"o":{"sIds":["1"]},"t":"sh"},"914":{"i":{"co":{"cIds":{"143":["13023"]}}},"o":{"sIds":["35"]},"t":"sh"},"962":{"i":{"co":{"cIds":{"113":["12996"]}}},"o":{"sIds":["28"]},"t":"sh"},"895":{"i":{"co":{"cIds":{"35":["12954"]}}},"o":{"sIds":["10"]},"t":"sh"},"68":{"i":{"co":{"cIds":{"5":["12949"]}}},"o":{"sIds":["17"]},"t":"sh"},"873":{"i":{"co":{"cIds":{"147":["10885"]}}},"o":{"sIds":["37"]},"t":"sh"},"112":{"i":{"co":{"cIds":{"83":["12999"]}}},"o":{"sIds":["23"]},"t":"sh"},"159":{"i":{"co":{"cIds":{"143":["13026"]}}},"o":{"sIds":["43"]},"t":"sh"},"932":{"i":{"co":{"cIds":{"926":["13036","13035","13034","13037"]}}},"o":{"sIds":["45"]},"t":"sh"},"144":{"i":{"co":{"cIds":{"143":["13027","13024","13025","13026","13028"]}}},"o":{"sIds":["36"]},"t":"sh"},"967":{"i":{"co":{"cIds":{"113":["13071"]}}},"o":{"sIds":["26"]},"t":"sh"},"54":{"i":{"co":{"cIds":{"53":["13017","13019","13020","13018","13021"]}}},"o":{"sIds":["13"]},"t":"sh"},"127":{"i":{"co":{"cIds":{"5":["12950"]}}},"o":{"sIds":["32"]},"t":"sh"},"36":{"i":{"co":{"cIds":{"35":["12958","12953","12956"]}}},"o":{"sIds":["9"]},"t":"sh"},"82":{"i":{"co":{"cIds":{"5":["12947"]}}},"o":{"sIds":["19"]},"t":"sh"},"876":{"i":{"co":{"cIds":{"143":["13027","13024","13025","13026","13028"]}}},"o":{"sIds":["41"]},"t":"sh"},"879":{"i":{"co":{"cIds":{"878":["13005"]}}},"o":{"sIds":["40"]},"t":"sh"},"961":{"i":{"co":{"cIds":{"113":["12994","13068"]}}},"o":{"sIds":["29"]},"t":"sh"},"933":{"i":{"co":{"cIds":{"926":["13061","13062","13067"]}}},"o":{"sIds":["46"]},"t":"sh"},"130":{"i":{"co":{"cIds":{"128":["12983","12985","12984","12986","12987","12988","12989"]}}},"o":{"sIds":["33"]},"t":"sh"},"875":{"i":{"co":{"cIds":{"143":["13027"]}}},"o":{"sIds":["39"]},"t":"sh"},"893":{"i":{"co":{"cIds":{"22":["10885"]}}},"o":{"sIds":["6"]},"t":"sh"},"971":{"i":{"co":{"cIds":{"970":["1"]}}},"o":{"sIds":["27"]},"t":"sh"},"91":{"i":{"co":{"cIds":{"83":["12997","12998","13000","13001"]}}},"o":{"sIds":["22"]},"t":"sh"},"52":{"i":{"co":{"cIds":{"5":["12946"]}}},"o":{"sIds":["12"]},"t":"sh"},"960":{"i":{"co":{"cIds":{"1":["12942"]}}},"o":{"sIds":["2"]},"t":"sh"},"119":{"i":{"co":{"cIds":{"5":["12945"]}}},"o":{"sIds":["30"]},"t":"sh"},"964":{"i":{"co":{"cIds":{"113":["13069"]}}},"o":{"sIds":["24"]},"t":"sh"}},"sections":{"12":{"name":"Lab Issues","conditions":["52","504","931"]},"8":{"name":"Billing/Insurance Issues","conditions":["34","504","931"]},"22":{"name":"Patient Account Help(Mirror Form 2)","conditions":["91","82","504","931"]},"5":{"name":"Charting Issue","conditions":["19","17","504","931"]},"10":{"name":"Refund Assistance Needed","conditions":["895","34","504","931"]},"21":{"name":"Un-Merge Account","conditions":["89","82","504","931"]},"43":{"name":"Unknown Prescription Refill Request","conditions":["159","142","504","931"]},"32":{"name":"Provider App Outage","conditions":["127","504","931"]},"31":{"name":"Family Account","conditions":["121","119","504","931"]},"42":{"name":"In House","conditions":["917","142","504","931"]},"18":{"name":"Form 3","conditions":["74","68","504","931"]},"3":{"name":"Yes Provider App","conditions":["504","931"]},"28":{"name":"Not Listed","conditions":["962","112","82","504","931"]},"45":{"conditions":["932","517","504","931"]},"34":{"name":"Prescription/RX Issue","conditions":["142","504","931"]},"19":{"name":"Patient Account Help","conditions":["82","504","931"]},"23":{"name":"Occupational Health/Employer Paid Services","conditions":["112","82","504","931"]},"4":{"name":"Charting Error","conditions":["17","504","931"]},"40":{"name":"Different State","conditions":["879","875","142","504","931"]},"15":{"name":"iPad","conditions":["898","896","52","504","931"]},"11":{"name":"Unable to adjust self-pay","conditions":["51","34","504","931"]},"9":{"name":"Billing/Insurance","conditions":["36","34","504","931"]},"44":{"name":"Scheduling Issues","conditions":["517","504","931"]},"33":{"name":"Provider App Outage Form","conditions":["130","127","504","931"]},"26":{"name":"Deactivate/Reactivate Org","conditions":["967","112","82","504","931"]},"37":{"name":"iPad App","conditions":["873","144","142","504","931"]},"13":{"name":"Lab Issues","conditions":["54","52","504","931"]},"46":{"conditions":["933","517","504","931"]},"24":{"name":"Add New Org","conditions":["964","112","82","504","931"]},"35":{"name":"In House","conditions":["914","142","504","931"]},"16":{"conditions":["897","52","504","931"]},"6":{"name":"iPad","conditions":["893","19","17","504","931"]},"36":{"name":"Prescription/RX Issues","conditions":["144","142","504","931"]},"1":{"conditions":["931"]},"39":{"name":"Ayva/Bravado Issue","conditions":["875","142","504","931"]},"17":{"name":"Provider App Log In Issues","conditions":["68","504","931"]},"25":{"name":"Update Org Admin","conditions":["966","112","82","504","931"]},"14":{"name":"Lab Issue Device","conditions":["896","52","504","931"]},"20":{"name":"Patient Account Help(Mirror Form 2)","conditions":["84","82","504","931"]},"27":{"name":"Reactivate","conditions":["971","967","112","82","504","931"]},"2":{"conditions":["960","931"]},"38":{"name":"Prescription/RX Issues Pt 2","conditions":["874","142","504","931"]},"30":{"name":"Family Account","conditions":["119","504","931"]},"7":{"conditions":["894","17","504","931"]},"29":{"name":"Org Patient","conditions":["961","112","82","504","931"]},"41":{"name":"Prescription/RX Issues Pt 3","conditions":["876","142","504","931"]}},"questions":{"22":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"976":{"type":"tl","label":"Admin Phone Number","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"977":{"type":"tl","label":"Admin Name","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"113":{"type":"cs","label":"Assistance Help Needed","description":"","validation":{"rq":true},"jiraField":"customfield_11163","questionKey":""},"120":{"type":"cs","label":"Family Account","description":"","validation":{"rq":true},"jiraField":"customfield_11179","questionKey":""},"147":{"type":"cm","label":"Device Used","description":"","validation":{"rq":false},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"963":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"925":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"124":{"type":"ts","label":"MRN of Primary Account","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"981":{"type":"rt","label":"Organization Address","description":"Street - Suite/Unit - City - State Abbreviation - Zip Code","validation":{"rq":true},"choices":[],"questionKey":""},"78":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"881":{"type":"ts","label":"Provider's Prescribing State","description":"","validation":{"rq":true,"mnc":2,"mxc":2},"jiraField":"customfield_11172","questionKey":""},"918":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"23":{"type":"ts","label":"if iPad App, what version is being used","description":"How to Find Version History Hyperlink","validation":{"rq":true},"choices":[],"questionKey":""},"929":{"type":"cd","label":"Urgency ","description":"If your request is critical, please select in dropdown.","validation":{"rq":false},"choices":[{"id":"10892","label":"Critical (>5 Mins)"},{"id":"10894","label":"Not Urgent (2-4 Days)"}],"defaultAnswer":{"choices":["10894"]},"questionKey":""},"135":{"type":"ts","label":"if iPad App, what version is being used","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"128":{"type":"cs","label":"Provider App Outage","description":"","validation":{"rq":true},"jiraField":"customfield_11161","questionKey":""},"88":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"77":{"type":"ts","label":"Employee Email who needs Assistance","description":"","validation":{"rq":true,"rgx":{"p":"","m":"Please enter valid Carbon Health Email"}},"choices":[],"defaultAnswer":{"text":""},"questionKey":""},"40":{"type":"ts","label":"if iPad App, what version is being used","description":"How to Find Version History Hyperlink","validation":{"rq":true},"choices":[],"questionKey":""},"920":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"90":{"type":"pg","label":"Case(s) To Be Moved","description":"Write Out Which Cases Belong To Which Patient.","validation":{"rq":true},"choices":[],"questionKey":""},"139":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"870":{"type":"da","label":"What is Date of Service","description":"","validation":{"rq":true},"jiraField":"customfield_11165","questionKey":""},"117":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"908":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"919":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"936":{"type":"tl","label":"Email of Employee Who Needs Access","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"26":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"jiraField":"customfield_11168","defaultAnswer":{"choices":["13002"]},"questionKey":""},"843":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"jiraField":"customfield_11158","questionKey":""},"907":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"134":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"884":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"928":{"type":"tl","label":"Other Information","description":"","validation":{"rq":false},"jiraField":"customfield_11183","questionKey":""},"877":{"type":"rt","label":"What Pharmacy Should the Prescription be Sent to?","description":"Name and Address","validation":{"rq":true},"jiraField":"customfield_11169","questionKey":""},"973":{"type":"tl","label":"Admin Name","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"24":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"jiraField":"customfield_11159","questionKey":""},"888":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"83":{"type":"cs","label":"Patient Account Help","description":"","validation":{"rq":true},"jiraField":"customfield_11164","questionKey":""},"970":{"type":"cs","label":"Action Needed","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Reactivate","other":false},{"id":"2","label":"Deactivate","other":false}],"questionKey":""},"35":{"type":"cs","label":"Billing/Insurance Issues","description":"","validation":{"rq":true},"jiraField":"customfield_11156","questionKey":""},"79":{"type":"ts","label":"if iPad App, what version is being used","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"5":{"type":"cs","label":"Support Needed","description":"What is the issue you are having","validation":{"rq":true},"jiraField":"customfield_11155","questionKey":""},"980":{"type":"tl","label":"Admin Fax Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"59":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"87":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"913":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"890":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"116":{"type":"ts","label":"Clinic Location","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"984":{"type":"tl","label":"Organization name","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"76":{"type":"ts","label":"Employee Name who needs Assistance","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"909":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"138":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"978":{"type":"tl","label":"Admin Email","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"148":{"type":"ts","label":"What App version is being used on iPad","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"889":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"910":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"57":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"935":{"type":"tl","label":"Name of Employee Who Needs Access","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"924":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"921":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"80":{"type":"pg","label":"Description of Issue","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"137":{"type":"cs","label":"Is this happening on a single patient's chart or ALL patient charts","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Single Patient","other":false},{"id":"2","label":"Any/All Charts","other":false}],"questionKey":""},"923":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"979":{"type":"tl","label":"Admin Fax Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"968":{"type":"tl","label":"Organization name","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"1":{"type":"cs","label":"Is This a Provider App Issue?","description":"","validation":{"rq":true},"jiraField":"customfield_11154","questionKey":""},"39":{"type":"cm","label":"Device Used","description":"","validation":{"rq":true},"choices":[{"id":"10885","label":"iPad App"},{"id":"10886","label":"Google Chrome"},{"id":"10887","label":"Safari"},{"id":"10888","label":"Other"}],"questionKey":""},"878":{"type":"cs","label":"Are the Provider and Pharmacy Located in the Same State?","description":"","validation":{"rq":false},"jiraField":"customfield_11170","questionKey":""},"912":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["13002"]},"questionKey":""},"25":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"60":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"658":{"type":"at","label":"Screenshot of Issue","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"872":{"type":"tl","label":"Who is the Prescribing Provider","description":"","validation":{"rq":true},"jiraField":"customfield_11167","questionKey":""},"983":{"type":"tl","label":"Organization Name That Patient Belongs To?","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"69":{"type":"cs","label":"Provider App Log In Issues","description":"","validation":{"rq":true},"jiraField":"customfield_11162","questionKey":""},"934":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"58":{"type":"ts","label":"if iPad App, what version is being used","description":"How to Find Version History Hyperlink","validation":{"rq":true},"choices":[],"questionKey":""},"53":{"type":"cs","label":"Lab Issues","description":"","validation":{"rq":true},"jiraField":"customfield_11176","questionKey":""},"42":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"972":{"type":"cs","label":"Is this a Legacy Organization?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Yes","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"880":{"type":"ts","label":"Pharmacy's Location","description":"","validation":{"rq":true,"mnc":2,"mxc":2},"jiraField":"customfield_11171","questionKey":""},"149":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"20":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"jiraField":"customfield_11174","questionKey":""},"965":{"type":"tl","label":"Organization name","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"927":{"type":"tl","label":"Which pseudo provider/staff account is the availability for? (e.g. Berkley Provider UC) ","description":"","validation":{"rq":true},"jiraField":"customfield_11182","questionKey":""},"937":{"type":"cs","label":"Job Title of Employee Who Needs Access","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Clinic Manager","other":false},{"id":"2","label":"Director","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"922":{"type":"tl","label":"Name of Clinic or Facility","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"871":{"type":"tl","label":"Which Medication","description":"","validation":{"rq":true},"jiraField":"customfield_11166","questionKey":""},"969":{"type":"tl","label":"Organization name","description":"This is the name shown on the Provider app","validation":{"rq":true},"choices":[],"questionKey":""},"886":{"type":"cs","label":"Specialty","description":"","validation":{"rq":true},"choices":[{"id":"10882","label":"Primary Care"},{"id":"10881","label":"Urgent Care"},{"id":"10883","label":"Virtual Care"},{"id":"10885","label":"Workplace Health","other":false},{"id":"10884","label":"N/A"}],"questionKey":""},"125":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"18":{"type":"cs","label":"Charting Issue","description":"","validation":{"rq":true},"jiraField":"customfield_11160","questionKey":""},"143":{"type":"cs","label":"Prescription/RX Issue","description":"","validation":{"rq":true},"jiraField":"customfield_11178","questionKey":""},"114":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"982":{"type":"rt","label":"Are there any services that differ in price from the generic fee schedule?","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"41":{"type":"ts","label":"MRN of Patient","description":"","validation":{"rq":true,"rgx":{"p":"^\\d+$","m":""}},"choices":[],"questionKey":""},"905":{"type":"cd","label":"Urgency ","description":"","validation":{"rq":false},"choices":[{"id":"13002","label":"Not Urgent"},{"id":"13003","label":"Critical"},{"id":"13022","label":"Urgent"}],"defaultAnswer":{"choices":["10894"]},"questionKey":""},"150":{"type":"pg","label":"Description","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"868":{"type":"rt","label":"MRN(s) of Patient(s) to Add/Remove","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"172":{"type":"pg","label":"Please outline the steps you have implemented and any schedule adjustments you are making.","description":"","validation":{"rq":true},"jiraField":"customfield_11184","questionKey":""},"930":{"type":"cs","label":"Do you understand?","description":"","validation":{"rq":true,"ch":"1"},"choices":[{"id":"1","label":"Yes","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"915":{"type":"tl","label":"Clinic Name (find me)","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"131":{"type":"cs","label":"Are other websites on your device loading?","description":"","validation":{"rq":true},"jiraField":"customfield_11180","questionKey":""},"926":{"type":"cs","label":"Scheduling Issue","description":"","validation":{"rq":false},"jiraField":"customfield_11181","questionKey":""},"975":{"type":"tl","label":"Admin Email","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"136":{"type":"cs","label":"Is this happening only for you or everyone at your clinic?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Just Myself","other":false},{"id":"2","label":"Entire Clinic","other":false}],"questionKey":""}}},"uuid":"f662f3a8-3d40-4d77-8f9b-c0498b46a872"},"linkedJiraFields":["customfield_11180","customfield_11181","customfield_11160","customfield_11182","customfield_11161","customfield_11183","customfield_11184","customfield_11162","customfield_11163","customfield_11164","customfield_11165","customfield_11166","customfield_11167","customfield_11168","customfield_11169","customfield_11170","customfield_11171","customfield_11172","customfield_11174","customfield_11154","customfield_11176","customfield_11155","customfield_11178","customfield_11156","customfield_11179","customfield_11158","customfield_11159"]},"key":""},"portalWebFragments":{"headerPanels":[],"subheaderPanels":[],"footerPanels":[],"pagePanels":{"propertyPanels":[],"legacyPropertyPanels":[]}}}