For detailed instructions on how to complete this form, click the Report a Correction Job Aid PDF below:
Location or Provider Name* must provide value
Location or Provider Name* must provide value
Employer Affiliation Affiliated Ascension Medical Group
NPI
Created Date Today M-D-Y
Updated Date Today M-D-Y
Your First Name* must provide value
Your Last Name* must provide value
Your Email* must provide value
Please re-enter your email* must provide value
The above emails do not match. Your Phone* must provide value
Your Relationship to Ascension* must provide value
Patient/Customer Doctor/Nurse/Clinician Associate Other
You chose "Other" as your affiliation to Ascension. Please provide your affiliation.
Requested completion date: Today M-D-Y
* must provide value
AL - Birmingham AL - Mobile CT - Bridgeport DC - Washington DC FL - Jacksonville FL - Pensacola IL - Arlington Heights IN - Evansville IN - Indianapolis KS - Wichita MD - Baltimore MI - Detroit MI - Grand Blanc MI - Kalamazoo MI - Rochester MI - Saginaw MI - Tawas MO - St. Louis NY - Amsterdam NY - Binghamton OK - Tulsa TN - Nashville TX - Austin TX - Waco WI - Appleton WI - Milwaukee
Ministry Acronym ALBIR ALMOB CTBRI DCWAS FLJAC FLPEN ILARL INEVA ININD KSWIC MDBAL MIDET MIGRA MIKAL MIROC MISAG MITAW MOSTL NYAMS NYBIN OKTUL TNNAS TXAUS TXWAC WIAPP WIMIL
Category
If you need to submit a ticket with multiple categories, please select 1 and provide details in the comment field at bottom of form.
* must provide value
Add a Non-provider Location Add Provider Address Affiliation Awards Biography Board Certification Change Employment: AMG/Affiliated Credentials Delete/ Deactivate Education Fellowship GMB Listing (Add/Update) Google Store Code Internship Name Change Non-Provider Address Change Non-Provider Phone Change Phone/Fax Photo Professional Statement Residency Scheduling Appointments Search - (Google, Bing) Specialty URL Link Video
Is this deletion/ deactivation permanent or temporary Permanent
Temporary
Category Other* must provide value
Add a Non-provider Location = Add a new location to healthcare.ascension.org Find a Location site. If you want to add a location for a provider, choose the Address category.
Add Provider = Add a new provider profile to Healthcare.Ascension.org Find a Doctor site.
Address = Add, change, or delete a practice address.
Non-Provider Address Change = Add, change, or delete an address for Find a Location.
Affiliation = Add, change, or delete hospital affiliations for a provider. Affiliations are the hospital facilities where a provider has been granted privileges.
Biography = Add or modify a provider's Biography. The Biography appears in the 'About' section of the provider's profile.
Board Certification = Add, change, or delete a provider's Board or Professional Certifications. Certifications appear in the 'Qualifications' section of the provider's profile.
Change Employment: AMG/Affiliated = Provider is switching from AMG to Affiliated or vice versa.
Credentials = Add, change, or delete a provider's Credentials (MD, APNP, PA, FACOG, etc.)
Delete Provider = Completely remove a provider profile from Find a Doc.
Education = Add, change, or delete a provider's Education (Medical or Professional School).
Fellowship = Add, change, or delete Fellowship information.
Internship = Add, change, or delete Internship information.
Name Change = Change or correct a provider name on an existing profile.
Other = Submit a request that does not fall into the other categories.
Phone/Fax = Add, change, or delete a provider's phone or fax number.
Non-Provider Phone Change = Add, change, or delete a phone number for Find a Location.
Photo = Add, change, or delete a provider's photo.
Residency = Add, change, or delete Residency information.
Scheduling Appointments = Report an issue with online appointment scheduling.
Search - (Google, Bing) = Report an issue with Google or Bing search results for an AMG provider. For search issues related to Find a Doctor on healthcare.ascension.org, please submit a ServiceNow ticket.
Specialty = Add, Change or Delete a provider's specialty.
URL Link = Report an issue with the links displayed within a provider profile.
Video = Report an issue with the video displayed for a provider.
GMB Listing (Add/Update) - Ascension creates separate GMB listings for each provider practice location. GMB listings are connected to reputation.com (RDC) to sync the content. GMB = Google My Business
Google Store Code - The GMB store code serves as the unique ID. For providers, we use their NPI number. NPI#-2 and -3 serve as the second and third practice locations. For facilities, we use a unique taxonomy based on AIS code, city and consecutive numbers. Digital Marketing creates these numbers from the request submitted. GMB = Google My Business. A phone number, address and the exact name of the facility are required for new facility GMB store codes. Please provide these in the Description field below.
Professional Statement - A small content block which appears on the provider's landing page, it's to add additional content regarding clinical expertise in procedures or contributions to the specialty.
Awards - When submitting award information, be sure to include the year won, the organization giving the award and any links to the organization. Also,be sure to include the name of the award itself.
Are you adding a new or updating a current photo?
Note: If you are requesting to add a new or update a current photo and do not provide a photo below, please anticipate a delay in the fulfillment of this request.
* must provide value
Yes
No
Upload picture* must provide value
Upload File If Necessary
RDC Internal ID
MD-Staff Provider ID
Values Missing Flag View equation
In order to submit this form, you must complete all required fields.
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