Electronic Health Record Sharing System (ehrss) Healthcare Provider Registration Form

Transcription

1 Electronic Health Record Sharing System (ehrss) Healthcare Provider Registration Form Please refer to the Registration Guide at the back of this form, Guide for Healthcare Provider Registration, Conditions of Registration of HCPs in Electronic Health Record Sharing System (ehrss) and Code of Practice for Using ehr for Healthcare before filling the form. Application is hereby made for Registration under Section 19(4) of the Electronic Health Record Sharing System Ordinance (Cap.625). PART 1 Particulars of Healthcare Provider (HCP) Official Name of HCP in English * (see note 4) Official Name of HCP in Chinese * Name of HCP in ehrss in English * (see note 5) Name of HCP in ehrss in Chinese * Short Name of HCP in English * (see note 6) Short Name of HCP in Chinese * Type of Establishment (choose only one) Private Hospital (Cap. 165) Nursing Home (Cap. 165) Medical Clinic (Cap. 343) Dental Company (Cap. 156) Residential Care Homes (Elderly Persons) (Cap. 459) Residential Care Homes (Persons with Disabilities) (Cap. 613) Specified entity that engages a healthcare professional to perform healthcare at one premises (provide number of document as proof of establishment) Business Registration Certificate of Incorporation Other document Telephone Number * (852) Address of HCP * Mobile Number (see note 7) (852) Fax Number (see note 8) (852) Website Address of HCP * Number of Healthcare Service Location(s) joining ehrss: (see note 9)

2 Address of HCP in English * Room/Floor Building Street number/name District ehr Registration Centre Opening Hours # Monday Friday Tuesday Saturday Wednesday Sunday Thursday Public Holiday PART 2 Information of Applicant The applicant is an individual incorporated company / organisation 2.1 Particulars of Applicant or Authorised Person of Company / Organisation Title Mr. 先 生 Mrs. 太 太 Miss 小 姐 Ms. 女 士 Doctor 醫 生 Professor 教 授 醫 師 Name in English (must be the same as shown on HKIC / Travel Document) Name in Chinese (must be the same as shown on HKIC / Travel Document) Post Title Hong Kong Identity Card/Travel Document Number Correspondence Address (if different from the above HCP address) Telephone Number Fax Number Address 2.2 Particulars of User Administrator (see note 10) Same as Applicant / Authorised Person Title Mr. 先 生 Mrs. 太 太 Miss 小 姐 Ms. 女 士 Doctor 醫 生 Professor 教 授 醫 師 Name in English (must be the same as shown on HKIC / Travel Document) Post Title Telephone Number Address

3 Part 3 - Important Notes For Application for Registration in ehrss 3.1 Responsibilities of Registered Healthcare Providers A registered healthcare recipient s (HCR) health data in ehrss shall comply with ehrss Ordinance (Cap. 625), Personal Data (Privacy) Ordinance (Cap. 486) (PD(P)O) and Code of Practice (COP) issued by ehrc as well as the Conditions of Registration of Healthcare Providers in ehrss and other requirements set out by the Commissioner for Electronic Health Record (ehrc) for registration in joining the ehrss. HCP should indemnify ehrc for any loss or damages resulting from: any breach of the HCP of the conditions imposed by ehrc in accordance with the ehrsso; any breach of any applicable laws by the HCP or its staff in relation to any access or use of ehrss; or any allegation for copyright infringement due to sharing of data provided to ehrss 3.2 Use of Data A registered HCR s health data in ehrss is not a complete health record and the information contained in it may not be up-to-date or accurate and shall not be taken as a substitution of the clinical records in HCP. HCP and his/her staff must not solely rely on the data and information obtained from ehrss for providing healthcare as they are intended to be for reference only. ehrc makes no representation or warranty regarding ehrss that: it is fit for a particular purpose it is free from any computer virus or any risk of causing damage to others systems it is available, accurate and in proper functioning at any time. ehrc is not responsible for delivery of data over the internet or handling of data by systems that are not owned or operated by ehrc. Requirements and specifications governing the operation of ehrss may be amended and updated from time to time. Any pre-existing intellectual property rights in the data provided to ehrss remains unaffected under the operation of ehrss. 3.3 Limitation of Liability ehrc would endeavour to ensure proper operation and security protection of ehrss. However ehrc is not in a position to verify the accuracy of the data being shared in the ehrss and it is not possible for the ehrc to completely prevent any misuse of the data. ehrc is not liable for: any unauthorised access or use of ehr but ehrc will take appropriate and reasonable steps to protect the security of the data in ehrss any direct, indirect, special or consequential losses or damages arising from access to or use of ehrss, use of any ehr in ehrss, or providing or obtaining data or information to and from ehrss such act or thing for which any liability is excluded by the ehrss Ordinance. PART 4 Declaration of Applicant / Authorised Person I declare that- I have the lawful authority from the healthcare provider to submit the application. The information given in Part 1 and Part 2 of this application form and Healthcare Service Location Information (provided together with this application or separately in the future, if applicable) is true and correct to the best of my knowledge and I have understood the information for applying for registration in ehrss. Signature of Applicant / Authorised Person Organisation Chop Date * Information will be displayed on ehrss HCP register < # For Healthcare Service Location providing ehrss registration services only, information will be displayed on ehrss HCP register Official Use Only Processed by HCP ID

4 Registration Guide (1) Below documents can be downloaded from ehrss website: a. Guide for Healthcare Provider Registration in ehrss b. Conditions of Registration of HCP (Private Hospitals) in ehrss c. Conditions of Registration of HCP (other than Private Hospitals) in ehrss d. Code of Practice for Using ehr for Healthcare e. Licence Agreement for use of Encapsulated Linkage Security Application (ELSA) and Hong Kong Clinical Terminology Table (HKCTT) (duplicate original copies) (2) The duly completed registration form, should be submitted by post to: Electronic Health Record Registration Office Unit 1193, 11/F, Kowloonbay International Trade & Exhibition Centre, 1 Trademart Drive, Kowloon Bay, Hong Kong (Enquiry Number: ) (3) The applicant should submit the following documents together with the application form: Signed copies of Licence for Use of Encapsulated Linkage Security Application (ELSA) and Hong Kong Clinical Terminology Table (HKCTT) Healthcare Service Location Information (HSL01) for each healthcare service location joining ehrss (required for HCP having more than one service location) Photocopy of supporting documents for HCP Registration (specified in the Guide for Healthcare Provider Registration and listed below) Type of Establishment Supporting Document for Registration (Photocopy only) Private Hospital (Cap. 165) Certificate of Registration of Private Hospital Nursing Home (Cap. 165) Certificate of Registration of Nursing Home Medical Clinic (Cap. 343) Certificate of Registration of Medical Clinic Dental Company (Cap. 156) Acknowledgement Letter issued by the Department of Health in receipt of Particulars of Directors or Managers or Persons who perform dental operations Residential Care Homes (Elderly Homes) Licence of Residential Care Home for the Elderly (Cap. 459) Practising Certificate of Healthcare Professional Residential Care Homes (Elderly Homes) (Cap. 613) Licence of Residential Care Home for Persons with Disabilities / Certificate of Exemption of Residential Care Home for Persons with Disabilities Specified entity that engages a Healthcare Professional to perform healthcare at one premises Practising Certificate of Healthcare Professional Business Registration Certificate / Certificate of Incorporation or any other document as a proof of establishment (organisation) Identity Document (individual) Practising Certificate of Healthcare Professional (4) Official Name of HCP should be the same as listed in supporting documents. (5) Name of HCP in ehrss is for display in the ehr Sharing System. (6) Short Name of HCP is for display in the ehr Sharing System and SMS messages to HCR informing them of account activities such as ehr records being accessed. Maximum 25 English letters and 15 Chinese characters including spaces. (7) Hong Kong local mobile number is needed to receive activation code for Encapsulated Linkage Security Application (ELSA) installation (if applicable). (8) Fax number is required for uploading Healthcare Recipient related document. (9) Separate Healthcare Service Location Information (HSL01) should be submitted for each healthcare service location joining ehrss. Submission only required for HCP having more than one healthcare service location. (10) User Administrator is the contact point between HCP and ehr RO. A user account will be created for him/her in ehrss.

5 (11) Terms Abbreviations Long name Description HCP Healthcare Provider A healthcare provider that provides healthcare at one service location in Hong Kong HCR Healthcare recipient Means an individual for whom healthcare has been performed, is performed, or is likely to be performed in Hong Kong ehrss Electronic Health Record Sharing System Means an information infrastructure established and maintained by the Commissioner for keeping the records of the healthcare recipient and sharing and using data and information contained in those records ehr RO Electronic Health Record Registration Office The registration office of ehrss

6 PERSONAL INFORMATION COLLECTION STATEMENT Purposes of Collection We may collect a variety of information including name, address, telephone number(s), business registration and healthcare provider registration information of your organisation, and personal information including names, titles and contact information (e.g. telephone number(s) and address) of the in-charge and contact person in your organisation. The personal data or any information we collected from your organisation is used for your registration as a registered healthcare provider in the Electronic Health Record Sharing System (ehrss) and related matters under the ehrss Ordinance (Cap 625). Your registration is essential, as only healthcare staff working under registered healthcare providers can access information and function(s) in the ehrss. Unless for specified purpose stated in the ehrss Ordinance, using your personal information in ehrss for direct marketing is an offence. Classes of Transferees Except with your prior consent, we will not transfer or disclose the collected personal information to any third party except as stated below: (1) the Department of Health, Hospital Authority or any person or entity whom we may appoint in writing to assist in performing a function and exercising a power, pursuant to ehrss Ordinance; (2) any personnel, agent, adviser, auditor, contractor or service provider engaged by us to provide services or advice (e.g. technical, security or data processing service etc.) in connection with our operations; (3) any person to whom we are required to make disclosure under any law or court order applicable in Hong Kong. Access and Correction of Your Personal Data You have the rights of access and correction with respect to your personal data provided under Personal Data (Privacy) Ordinance. A reasonable fee will be charged for complying with your request. Enquiries Enquiries concerning personal data provided, including the making of access and correction should be addressed to: Electronic Health Record Registration Office Unit 1193, 11/F, Kowloonbay International Trade & Exhibition Centre, 1 Trademart Drive, Kowloon Bay, H.K. Fax: Hotline: ehr@ehealth.gov.hk