Technical Assistance

Technical Assistance

This form is for technical assistance purposes only. For questions related to Medication Assistance or Premium Assistance, please email DPH.ClientServices@illinois.gov.

Please do not submit multiple tickets regarding the same issue.

Requestor Information

Requestor First Name*

Requestor Last Name*

Requestor E-Mail Address*

Updates on IT requests will be sent to the email address provided.

Requestor Phone Number*

Phone

Program*

Select or enter value

Requestor Agency Name*

Request Type*

Select or enter value

Would you like to update or create documents?*

Select or enter value

Document Category*

Select or enter value

Document Type*

Select or enter value

Setup Request*

Please be advised that only lead agents or grant monitors should be submitting these requests. If you have Provide access, please submit your request via Provide.

Select or enter value

Document Name as it Appears on the Website*

Are you replacing or removing the document?*

Please select the best option below.

Select or enter value

Replacing*

Please include instructions on what you wish to be replaced. If you would like to replace the document name, please include it. If you are only replacing the document type "N/A".

Document Name*

Please include the name of the documents as it should appear in Provide.

VPN Request Type*

Select or enter value

Have you attempted to reset your password using security questions?*

If not, please exit the form and reset your password from Provide. If yes, check the box.

User Name as it appears in Provide*

Please provide your Provide user name. Ex. John Smith/idph/ilcare.

Note: Please ensure the email address above is attached to this Provide Enterprise account.

VPN Recipient First Name*

VPN Recipient Last Name*

E-mail Address of VPN Recipient*

Please ensure this is the same email address listed in Provide Enterprise. If it is not, update the email address listed in Provide before submitting this request.

Two Factor Authentication Phone Number*

The phone number entered will be called to verify the VPN user's identity.

Phone

Agency*

Enter your Agency name.

Name of Program*

Enter the Program's name. Ex. Client Services, Prevention (grant number), etc.

Agency Name*

Provide Enabled Agency?*

Select or enter value

Region*

Select or enter value

Bill to Person First Name*

Enter the name of the person that will be paying the $250 annual license fee.

Bill to Person Last Name*

Clients to Merge*

Please provide the Ryan White ID numbers of the clients that need to be merged.

IP Address to be Whitelisted*

Please enter the IP address you need to have whitelisted:

Document Changes*

Please include changes made to the document. This text will be included in Provide.

Would you like us to send out a PE alert?*

Select or enter value

What should the alert contain?*

Please include the language to be included in the PE alert.

Description of Issue*

Please provide as much detail as possible. Explain the steps you took, the views you clicked on, etc.

Comments to be Included in PE*

Please provide a brief description of the document.

File Upload*

Please include a screenshot of the issue. DO NOT include protected health information (PHI).

Drag and drop files here or

Type of Service Provider*

Select or enter value

Facility Name*

Please enter the facility name as it should appear in Provide.

Address*

Please provide the address as it should appear in Provide.

Street Address, State, City, and Zip.

Provider Name*

Please supply the provider's first name, middle initial, and last name.

Provide Enterprise User*

Will this provider be a Provide Enterprise user?

Select or enter value

Provide Enterprise User Name*

Provide Enterprise User Name. Ex. John Smith/idph/ilcare.

Prevention User*

Is this individual a Prevention User?

Select or enter value

Prevention Worker ID*

Please enter the Prevention Worker ID

Prevention Worker Type(s)*

Select or enter value

Prevention Employment Status*

Select or enter value

Training Completed

Provider's Address*

Please provide the street Address, State, City, and Zip.

Provider's Phone Number*

Please provide the individual's phone number.

Okay to Sent Text Messages?*

Select or enter value

Organization Name*

Please enter the organization name as it should appear in Provide.

Organization Address*

Please provide the address as it should appear in Provide.

Street Address, State, City, and Zip.

Vendor Agency*

Please provide the vendor agency.

Vendor Name*

Please provide the vendor name as it should appear in Provide.

Vendor Address*

Please provide the address as it should appear in Provide.

Street Address, State, City, and Zip.

Agency Default County*

Copy Security Settings?*

Select or enter value

Copy Security Settings From?*

Please provide the first and last name of the individual whose security settings will be copied.

Provider First Name, Middle Initial, and Last Name*

Provider Phone Number*

Provider E-mail Address*

Organization Type*

Program Type*

Select or enter value

User to be Deleted*

Please include the user's first and last name.

Role Change Detail*

Explain the role changes intended for the individual identified above. Also, explain the reason for the role change request.

Email Address*

Please provide an email address where your VPN instructions can be resent.

Comments

Please provide us with additional information below, if applicable.

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