REQUESTING ORGANIZATION INFORMATION:

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1 Instructions: Please fill in this form, print it, and sign it (5 pages in total). You may then either: fax the completed and signed forms to the ehealth Service Desk at or scan the completed and signed forms then them to If you require additional assistance please call the ehs Service Desk at: (local ). REQUESTING ORGANIZATION INFORMATION: Organization Service Type: Physician Office / Clinic Community Pharmacy Regional Health Authority Other (describe): RHA ONLY Hospital Emergency Hospital In-Patient Hospital Ambulatory Care/Out-patients Organization Home Care Long-Term Care/Affiliates Hospital Laboratory Service Type Physician Office/Clinic Primary Health Centre Hospital Radiology/Diagnostics (office use only) Public Health Mental Health/Addictions Hospital Pharmacy Organization Legal Name: Organization Name (if different from Legal Name): Primary Administrative Contact Name: Street Address: Postal Code: Telephone: City: Fax: Estimated number of initial users for Organization: Facilities (if different than above or more than 1) Facility Name 1 2 3

2 Designation of Authorized Approvers Please fill out the following section with a minimum of 1 Authorized Approver. Approvers will receive requests to verify that members of your Organization who request access to the ehr Viewer ( Users ) are allowed to have access. Authorized Approvers Last Name First Name Address Have a SCI or EMC account ehs Viewer Access Required 1 2 Yes No Yes No Yes No Yes No 3 Yes No Yes No 4 Yes No Yes No 5 Yes No Yes No Privacy, Security and Technical Assessment Although your initial access to the ehr Viewer will not be affected by this assessment, it must be completed and submitted as part of your Organization Approval Package. You may be contacted at a later date by our Privacy and Access Office to discuss any privacy or security concerns that may affect your continued use of the ehr Viewer. Technical Requirements Yes No Comments My organization meets the technical specifications outlined in the attached Technical Requirements document. Does your Organization use any of the following: Yes No Comments Electronic Medical Record (EMR) Pharmaceutical Information Program (PIP) Shared Client Index (SCI) or Enterprise Management Consul (EMC) Section A: Privacy and Security Assessment Yes No Comments 1) Is your Organization aware of privacy, The Health Information Protection Act (HIPA), and your responsibility to manage and secure personal health information?

3 2) Does your Organization have the following: a. someone designated as Privacy Officer or responsible for information privacy b. privacy and security policies and procedures c. confidentiality agreements signed by all staff d. privacy and security training for staff e. procedures in place to routinely or periodically audit user use/access to systems containing health information f. signed agreements in place with third parties (such as paper shredding services, computer support, etc. and other trustees) 3) Does your Organization provide information to patients about information management practices, including the purpose for collection, use and disclosure of their personal health information? Section B: Technical Security You may need to contact your IT Support to help answer some of these questions Yes No Comments 1) Are computer monitors placed so that unauthorized viewing is prevented? 2) Is equipment such as printers, fax machines, etc. located in secure areas, not accessible to the public? 3) Are the following technical and physical security safeguards in place where ehr Viewer access will occur: a. Controls to prevent screens from view if computer is unattended ie: password enabled screen save b. Anti-virus protection is installed with regular updates c. Anti-virus controls are enabled d. Firewalls are installed and enabled 4) Are Local Area Network and appropriate controls in place? 5) Are Wireless security settings configured and enabled?

4 Agreement This section must be signed by the head of the Organization requesting Approval. The head of the organization could be classified as the Owner, Chief Physician, Chief Executive Officer, or Chief Information Officer. I acknowledge that I, the trustee or a designated representative of the trustee, have read and agree to the responsibilities as outlined below as well as my obligations under HIPA. ehr Viewer Approved Organization Roles & Responsibilities Approved Organizations are responsible for ensuring that: The Organization s designated Authorized Approvers have completed the required training as well as have read and understand their roles and responsibilities. Appropriate physical, organizational and technological safeguards are in place within their organization to protect the security and confidentiality of the ehr Viewer data. ehr Viewer data is used only on a need-to-know basis for the authorized purposes in accordance with The Health Information Protection Act (HIPA) and the Joint Service and Access Policy (JSAP). The Organization is responsible for the management of Authorized Approvers including additions, deletions and changes in privileges. The Approved Organization and the Approver are accountable for the actions of the user. ehr Viewer Authorized Approver Roles & Responsibilities Authorized Approvers are responsible for ensuring that: Users complete the training available on the ehr Viewer Program Page. Approvers are responsible for going in and approving Viewer access requests for their Organizations as required. Note: ehr Viewer User Roles & Responsibilities Users are responsible for completing the training available in the ehr Viewer Program Page. Users are responsible for ensuring that the use of ehr Viewer data is on a need-to-know basis for the purpose of their health care work and is in accordance with their health organization s policies, procedures and HIPA and Joint Service Access and Policy (JSAP) agreement. Users who are viewing data within the ehr Viewer are responsible for selecting the correct person from the candidate list and for protecting the information from use for purposes other than health care delivery. User access is audited. Inappropriate use of the ehr Viewer shall be reported to the ehealth Saskatchewan s Chief Privacy Officer. Any violation of privacy legislation will be investigated and addressed. This may include immediate revocation of ehr Viewer access privileges. For additional details on any of these bullets, please see the Joint Services Access Policy (JSAP). A copy of which is available for download on the ehr Viewer Program Home Page. Head of the Organization Information & Signature: Name: Signature: Title: Date:

5 Technical Requirements These requirements must be met in order to access to the ehr Viewer. Each individual MUST have their own address and account Supported Browsers: Internet Explorer 8, 9, 10 and 11 Firefox (latest version) Chrome (latest version) Safari (latest version for Mac OS X) Safari (latest ios version for ipad only) Latest Version of Adobe Reader (required for viewing PDF documents in the browser) Latest Version of Adobe Flash Reader Minimum screen resolution: 1024 x 768 Verify that you can access the ehr Viewer web page: Verify you can access the ehr Viewer log in page: Add a shortcut on desktop or add to favorites