EIS Provider Staff Data Clean-Up Form

If a data entry cleanup is needed submit your request electronically.

What client do you need data clean-up performed on?


What type of clean-up do you need? (select one)

Transfer client from one office to another
Clients Demographics
Incorrect Entry Correct Entry
First Name: First Name:
Last Name: Last Name:
Date of Birth: Date of Birth:
Gender: Male Female Gender: Male Female
MaineCare #: Call Lynn @ 626-8651 MaineCare #: Call Lynn @ 626-8651
Component of EIS
Assessment ID: Start Date:
Authorization ID: Start Date:
Client Tracking ID: Start Date:
Notes ID: Start Date:
Process Title: Start Date:
Reportable Events ID: Start Date:
Transferring client from one office location to another within the same agency
Transfer from:
Transfer to:
Agency Name:
Agency Name:
Agency Address:
Agency Address:
Staff Person Contact Information
Name:
Phone:
Email Address: