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Schedule change request form

Schedule change request form

Effective April 1, 2015 all schedule changes must be requested using this on-line form. You will not be able to submit an incomplete form. PAIS and Ms. Grow will not be authorized to change schedules in any way unless this form is submitted.

Schedule change definitions

  • Cancel: To close a clinic day, time or session (ie: vacation, conference, illness, etc.)
  • Bump: The result of canceling a patient's appointment at the provider's request.
  • Freeze: To block a schedule, while still having the ability to schedule an appointment into a "frozen slot". You do not want to move any patients.
  • Edit: To change the way the provider's schedule is currently set up.
  • Open: To open on a schedule on a day when the provider does not have a schedule.
Schedule change request for (provider's name)  *Date submitted  *Submitted by  *Type of change (select one)  *Reason for change (select one)  *If 'Other', please explain Clinic locations affected by schedule change (please select all that apply) 









Requested schedule change beginning date  *Requested schedule change ending date  *Please list additional dates (mm/dd/yyyy, mm/dd/yyyy, etc) Rescheduling (select one)  *Additional comments