Expression of Interest

Transcription

1 Expression of Interest Purpose: This document is required for enrollment into the Saskatchewan EMR program. It identifies the clinic interested in the program and provides all clinic contact information. Additional Information: The name of the clinic s legal signing authority must be provided on the form. Process: Completed applications can be faxed, ed, or mailed to the Saskatchewan EMR Program Coordinator: Fax: emr@sma.sk.ca Mailing Address: Saskatchewan EMR Program A 21 st Street East Saskatoon, SK S7K 0C1 Once the Saskatchewan EMR Program receives the Expression of Interest form, an orientation site visit will be scheduled by an EMR Change Management Advisor (CMA). During this meeting the CMA will provide a detailed overview of the Saskatchewan EMR Program and next steps. If you DO NOT wish to have your clinic information shared with other strategic initiatives, related to the Saskatchewan EMR Program, please check here: The Saskatchewan EMR Program will not use or disclose this information for any other reason than specified without your expressed consent. You may at any time withdraw your consent for the uses stated above by contacting the Saskatchewan EMR Program Director in writing: Doug Dombrosky Director, Saskatchewan EMR Program Saskatchewan Medical Association A 21st Street East Saskatoon, SK, S7K 0C1 doug@sma.sk.ca Expression of Interest 1

2 Step 1: Provide Information Clinic Name: Clinic Legal Name: Clinic Address: (This is the address the Saskatchewan EMR Program will use for all correspondence and site visits) City: Phone: How many physicians in your clinic? Postal Code: Fax: How many physicians will be using the EMR? How many staff in your clinic? How many staff will be using the EMR? Step 2: Designate a clinic contact Please designate a primary contact to coordinate EMR activities. First name: Salutation: (Dr., Ms., Mr., Mrs.): Office phone: Last name: Title: Direct line/ext.: Primary contact address: Clinic address: Expression of Interest 2

3 Step 3: Please provide the following information FIRST NAME OF PHYSICIAN ENROLLING IN PROGRAM LAST NAME OF PHYSICIAN ENROLLING IN PROGRAM FULL TIME / PART TIME CLINIC LEGAL SIGNING AUTHORITY (Yes/No) Step 4: Please provide the following information about physicians NOT enrolling in the Saskatchewan EMR Program FIRST NAME OF PHYSICIAN LAST NAME OF PHYSICIAN FULL TIME / PART TIME CLINIC LEGAL SIGNING AUTHORITY (Yes/No) Expression of Interest 3

4 Step 5: Provide current software information Please provide information about the clinic s current software environment. Current billing software: Current patient scheduling software: Current EMR software (if any): Do you currently have EMR funding or hardware software support provided from any other source? Yes No If yes, please provide additional information: EMR Office Use Only: CMA Name I verify this EOI is complete and accurate: Expression of Interest 4

5 Approval to Release Clinic Contact Information The Saskatchewan EMR Program occasionally shares clinic contact information and other corporate information about a clinic with other strategic initiatives related to adding value to a clinic s use of their EMR. When possible the EMR Program will notify you of such a disclosure. Please indicate if you would like to share clinic information for the following purpose: Provided to: Med Access, QHR Technologies (EMR vendors) who will contact you about EMR Software products. Yes No If yes, please provide name of person the EMR vendors should contact: Name: Phone: When would you like the Saskatchewan EMR Program to release the clinic information to the vendors? Immediately One Month Two Months Other What is the best time of day for a vendor to contact the clinic? Completed forms may be ed or faxed to the Saskatchewan EMR Program: Phone: (306) Fax: (306) emr@sma.sk.ca Expression of Interest 5