KEY DATA ITEMS CHANGE FORM
TO:			Salt Lake County Division of Substance Abuse  Attn:  Marjeen Nation
FROM:
			Name of Clinic				Clinic ID
			Person Completing Form				Phone #
DATE:
RE:			MIS Corrections
I am requesting the following data elements to be changed:
			On the County's system
			On our agency's Dr. Data system
					Original Entry			Correct Entry
								(leave blank if no change)
			Client ID		__ __ __ __ __ __ __ __ __ __		to	__ __ __ __ __ __ __ __ __ __
			Date of Admission		__ __ / __ __ / __ __		to	__ __ / __ __ / __ __
			Date of Discharge		__ __ / __ __ / __ __		to	__ __ / __ __ / __ __
			Type of Program		__ __		to	__ __
			ASAM Level		__ __		to	__ __
			Facility Code		__		to	__
			Funding Code		__		to	__
				Reason For Change:
						Signature
						Date