Contact Us
Please complete this form and one of our agents will reply to you by email as soon as possible.
Account will be disabled at 11:59 PM on the selected day unless otherwise specified.
Date this change should take effect
Staff First and Last Name
Staff Number
The name of your clinical Supervisor
Please check as many as apply.
If you check other in Degree/License/Certification, please briefly describe below, or add an additional note if necessary.
Please List all Licenses:
a) License#
b) State
c) Type
a) License#
b) State
c) Type
Please list the cost center(s) associated with this request.
Please list the Service Code(s) associated with this request.
Service date(s) associated with this request
The Reference Number(s) associated with this request
Date of deadline
The primary program for which you work (if available)
Percentage of fees to be attributed to this Policy.
If yes, name of RBA card.
Description of the Door or doors to which access is needed
The client number(s) associated with this request.
If you are opening this ticket on behalf of someone else, please provide the person's name and email address.
Please provide the best phone number, with area code, at which to reach you or the person for whom you are submitting the ticket.
The location related to this ticket. Please give as much detail as possible:
1) Building Name
2) Address
3) Floor Number
4) Room Number
5) Description
1) Building Name
2) Address
3) Floor Number
4) Room Number
5) Description
The name of the supervising manager or supervisor. May be different from your Clinical Supervisor.
Your ticket will not be submitted until you see the ticket submission confirmation window. For instructions, please click here:
DeskPro Instructions