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Original Encounter ID (from Zendesk ticket)
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Follow Up Encounter ID (if applicable)
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Your Name
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Scheduled Appointment Details
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Provider's Name
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Provider's NPI
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Type of Provider
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Was the patient new or established with the provider?
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Month of the scheduled appointment
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Day of the scheduled appointment
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Year of the scheduled appointment
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Time of the scheduled appointment
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Appointment Preferences
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Earliest month the patient was available for the appointment
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Earliest day the patient was available for the appointment?
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Was this appointment new or rescheduled?
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Confirmation Details
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Month appointment confirmation was sent
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Day appointment confirmation was sent
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Year appointment confirmation was sent
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Time of day appointment confirmation was sent
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Provider Network Details
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Network Status
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Is the scheduled PCP a preferred PCMH provider?
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Specialist tier level at this location
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