Support

ESRD EQRS Support Ticket

* = Required

General Information

Please select your Network:

Facility Information

Facility Name (CCN):

Name of Person Submitting Ticket:

Email of Person Submitting Ticket:

Please update Phone and Fax information as needed.

Phone:

Ext:

Fax:

Reason for Initiating a Network Help Ticket

Please specify the type of issue you are experiencing:

Other:

Please provide details and additional information:

NOTE: DO NOT INCLUDE PATIENT NAME, DATE OF BIRTH, SOCIAL SECURITY # ON THIS TICKET REQUEST FORM AND DO NOT EMAIL PATIENT INFORMATION TO QUALITY INSIGHTS END-STAGE RENAL DISEASE NETWORKS, EVEN AS ATTACHMENTS, AS IT IS A HIPAA VIOLATION REPORTABLE TO CMS.

Please provide the EQRS ID Number for the EQRS record associated with this request. (If there is not an ID Number, please leave blank)

Submit