CTHMIS Support Form – Client Merge Request

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CTHMIS Support Form – Client…

CT HMIS - Submit a Client Merge Request

Use this form to submit a request to merge several CT HMIS client IDs for one distinct person into one “surviving” client ID, that will be used exclusively going forward. Merging the client records cannot be undone so please be sure to supply the correct IDs.

Submitting this form will create a ticket in our helpdesk and you will receive a form submission confirmation and ticket confirmation email.

Requestor Information

DO NOT INCLUDE CLIENT NAMES BELOW!

Name(Required)

First and last name of person requesting merge

First Name Last Name

Email(Required)

Phone(Required)

Name of Requesting Organization(Required)

Client Records to Merge

IMPORTANT NOTE: SUBMIT THIS FORM ONCE PER UNIQUE CLIENT MERGE REQUEST.

Please do not include any other clients when submitting each merge request. For example, if “John Doe” has multiple IDs in CT HMIS, list all of the duplicate IDs for “John Doe”. If you have multiple IDs representing more than one client, example: Two IDs for John Doe and two IDs for “Jane Doe”. You would enter the IDS for John Doe, submit the below form, then make another form submission for Jane Doe.

Client ID #1(Required)

Client ID #2(Required)

Client ID #3

Client ID #4

Client ID #5

Client ID #6

Client ID #7

Client ID #8

I certify that ALL of the above Client IDs are for the same client.(Required)

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Comments

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