Homeless Management Information Systems (HMIS) Correction Request Form

2. Homeless Management Information Systems (HMIS) Correction Request Form

4. Date of Request*
   Date of Request

   Date of Request

6. Organization Name*

8. User First Name*

9. User Last Name*

10. Email Address*

12. Contact Phone Number*

13. Extension

17. Type of Request: Delete Enrollment, Delete Service, Duplicate/Merge Client, Change Enrollment

19. Type of Request*

    Please check all the changes being requested

    1. Delete Enrollment
    2. Delete Service
    3. Change Enrollment
    4. Duplicated/Merge Clients
    5. Other
23. Name of Program Enrollment to be Delete*

    Full program name that the client is enrolled in

24. Enrollment Date*
    Enrollment Date

    Date Client Enrolled

26. a. Client ID*

27. a. Name of Client*

29. Reason for request*

33. Name of Service to be Deleted*

34. Date of Service*
    Date of Service

36. a. Client ID*

37. a. Name of Client*

39. Reason for the Request*

43. Name of Program Enrollment to be Changed*

    Full program name that the client is enrolled in

44. Enrollment Date*
    Enrollment Date

    Date Client is enrolled

46. Name of New Enrollment*

48. a. Client ID*

49. a. Client Name*

51. Reason for the Request*

55. a. Client ID*

56. a. Name of Client*

58. b. Client ID*

59. b. Client Name*

61. c. Client ID*

62. c. Client Name*

64. d. Client ID*

65. d. Client Name*

67. Which Client ID listed above is Correct?*
    -- Select One --abcd

69. How was it verified?*

    Describe the method of verification.

73. Description of Other Requests*

    Please fill in a detailed report of the issue or correction that you are experiencing

75. Upload a screen shot

    Upload a screen shot or file of what you are experiencing.

Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field