2023-12-13 14:38:01 -07:00
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name: Provider Request
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description: Request a new institution/clinic/insurance provider to be added to Fasten
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title: "[Provider Request]: "
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labels: ["provider", "enhancement"]
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projects: ["fastenhealth/fasten-onprem"]
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2023-12-13 14:21:58 -07:00
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assignees:
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2023-12-13 14:38:01 -07:00
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- AnalogJ
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2023-12-13 14:21:58 -07:00
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body:
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- type: markdown
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attributes:
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value: |
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2023-12-13 14:38:01 -07:00
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Thanks for taking the time to request a new Provider.
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Before you submit this request, please make sure that you've searched the existing issues to see if your provider has already been requested.
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2023-12-13 14:21:58 -07:00
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- type: input
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id: contact
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attributes:
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label: Contact Details
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description: How can we get in touch with you if we need more info?
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placeholder: ex. email@example.com
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validations:
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required: false
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2023-12-13 14:38:01 -07:00
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- type: input
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id: provider-name
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2023-12-13 14:21:58 -07:00
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attributes:
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2023-12-13 14:38:01 -07:00
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label: Provider/Institution Name
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description: What is the name of this Institution?
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placeholder: ex. Humana/Kaiser/John Hopkins
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2023-12-13 14:21:58 -07:00
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validations:
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required: true
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2023-12-13 14:38:01 -07:00
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- type: input
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id: provider-website
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2023-12-13 14:21:58 -07:00
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attributes:
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2023-12-13 14:38:01 -07:00
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label: Provider/Institution Website
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2023-12-14 18:55:24 -07:00
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description: Please share a link to the provider's homepage.
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2023-12-13 14:38:01 -07:00
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placeholder: ex. https://www.humana.com/
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2023-12-13 14:21:58 -07:00
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validations:
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required: true
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2023-12-14 18:55:24 -07:00
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- type: input
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id: provider-portal
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attributes:
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label: Patient Portal Login Website
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description: Please share a link to the provider's login page, where you can access your health records.
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placeholder: ex. https://ucsfmychart.ucsfmedicalcenter.org/ucsfmychart/Authentication/Login?
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validations:
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required: false
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2023-12-13 14:38:01 -07:00
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- type: input
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id: provider-ehr
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2023-12-13 14:21:58 -07:00
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attributes:
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2023-12-13 14:38:01 -07:00
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label: Provider EHR Platform
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description: If you know the name of the EHR platform that this provider uses, please share it.
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placeholder: ex. Epic MyChart, Cerner, Allscripts, etc
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validations:
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required: false
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- type: textarea
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id: additional-info
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2023-12-13 14:21:58 -07:00
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attributes:
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2023-12-13 14:38:01 -07:00
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label: Anything else we should know?
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description: Please share any additional information or links that you think would be helpful.
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validations:
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required: false
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2023-12-13 14:45:12 -07:00
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- type: markdown
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attributes:
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value: |
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If you haven't already, please consider filling out our [Personal Health Record Research Survey](https://forms.gle/zxxhUtKA1K82dUA76)
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to help us understand how you currently manage your health and the challenges you face with your existing tools.
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