REQUEST FOR INTEGRATED SERVICES

Transcription

1 REQUEST FOR INTEGRATED SERVICES Call the Service Desk (local ) if you are unclear about any fields below. Return to: Fax Number: : [email protected] CLINIC INFORMATION Clinic Legal Clinic Mailing Address City Postal Code Primary Contact Primary Contact # Primary Contact EMR INFORMATION EMR Application TELUS Health Med Access QHR Technologies Accuro Software Version SERVICES REQUESTED Check all that apply: Electronic Labs Note: pages 2 4 of form are required Chronic Disease Management (CDM) Note: only page 1 is required to request export of CDM to ehr Viewer Pharmaceutical Information Program (PIP) Note: pages 5 6 of form are required Signature of Applicant Date of application Date Request Submitted to ehealth Saskatchewan: Notes: SMA / PHC Requester Revised July 21, Page 1 of 6

2 ELECTRONIC LABORATORY RESULTS TO EMR Add Provider Request ELECTRONIC LABORATORY RESULTS TO EMR Call the Service Desk (local ) if you are unclear about any fields below. The Service Desk will process the request within two days from receiving the request. Return to: Fax Number: : [email protected] Check the option that applies: The clinic does not currently receive electronic labs and this is the initial request to receive The clinic already receives electronic lab results and this is a request to add or remove provider(s) CLINIC INFORMATION Clinic Legal Clinic Mailing Address City Clinic Postal Code Clinic Fax EMR Application TELUS Health Med Access QHR Technologies Accuro SASKATCHEWAN PROGRAM REPRESENTATIVE CONTACT INFORMATION Representative PHC Clinic (ehealth SK) SK EMR Program (SMA) PHC Site Administrator or SK EMR Change Management Advisor AUTHORIZING SIGNATURE Signing this document indicates all the required parties are aware of this implementation or removal and any required preparation or training will be completed. Signature Date Printed Date Request Submitted to ehealth Saskatchewan: Revised July 21, Page 2 of 6

3 ELECTRONIC LABORATORY RESULTS TO EMR Add Provider Request Note: Copy this page if more than two providers are to be added. CLINIC CONTACT RESPONSIBLE FOR VALIDATION Individual Completing the e-lab Routing Validation Training facilitated by: Requested Date to Implement Provider(s) with Electronic Labs: Note: Average time to implement is 2 weeks from date of request receipt ADD A NEW PROVIDER INFORMATION Does this provider practice in multiple locations? Yes No If Yes, which clinic is considered their primary location* * Note: Primary location EMR will be the recipient of all electronic labs ADD A NEW PROVIDER INFORMATION Does this provider practice in multiple locations? Yes No If Yes, which clinic is considered their primary location* * Note: Primary location EMR will be the recipient of all electronic labs ADD A NEW PROVIDER INFORMATION Does this provider practice in multiple locations? Yes No If Yes, which clinic is considered their primary location* * Note: Primary location EMR will be the recipient of all electronic labs Revised July 21, Page 3 of 6

4 ELECTRONIC LABORATORY RESULTS TO EMR Remove Provider Request Note: Copy this page if more than two providers need to be removed. CLINIC CONTACT RESPONSIBLE FOR VALIDATION Individual to Confirm Removal of e-lab Routing Requested Date to Remove Provider(s) Electronic Lab Feed: REMOVE EXISTING PROVIDER INFORMATION Reason for stopping electronic labs FORWARDING INFORMATION Effective Date Clinic Clinic Address Fax If no longer practicing in Saskatchewan, labs are to forward paper lab results to: REMOVE EXISTING PROVIDER INFORMATION Reason for stopping electronic labs FORWARDING INFORMATION Effective Date Clinic Clinic Address Fax If no longer practicing in Saskatchewan, labs are to forward paper lab results to: Revised July 21, Page 4 of 6

5 PIP TO EMR INTEGRATION REQUEST Add/Remove Provider Request REQUEST FOR PIP TO EMR INTEGRATION Call the Service Desk (local ) if you are unclear about any fields below. Return to: Fax Number: : [email protected] Check the option that applies: The clinic s EMR is not currently integrated to PIP and this is the initial request The clinic s EMR is already integrated to PIP and this is a request to add or remove provider(s) CLINIC INFORMATION Clinic Legal Clinic Mailing Address City Clinic Postal Code Clinic Fax EMR Application TELUS Health Med Access QHR Technologies Accuro NOTE: PIP to EMR is currently only available to QHR Technologies Accuro EMR. Average time to implement is 3 weeks from date of request receipt. SASKATCHEWAN PROGRAM REPRESENTATIVE CONTACT INFORMATION Representative PHC Clinic (ehealth SK) SK EMR Program (SMA) PHC Site Administrator or SK EMR Change Management Advisor AUTHORIZING SIGNATURE (Physician or Authorized Delegate to complete this section) Signing this document indicates all the required parties are aware of this PIP to EMR implementation or removal. Signature Date Printed Date Request Submitted to ehealth Saskatchewan: Revised July 21, Page 5 of 6

6 PIP TO EMR INTEGRATION REQUEST Add/Remove Provider Request LIST ALL PROVIDERS (If additional space is required, print this side of the request form and attach to request). Registrations must have: 1. Viewed the training video: 2. Obtained a PIP user account (refer to the document titled PIP Registration Process for instructions on how to obtain a PIP account) 3. Read and understand the Terms and Conditions of Use: Last Access to PIP View requires acknowledgement that users are responsible for insuring that the use is related to need to know for the purpose of their healthcare work only and is in accordance with their health organization s policies and procedures and the Health Information Protection Act (HIPA). User access is audited and inappropriate use of the information shall be reported to the Chief Privacy Offices of ehealth Saskatchewan and the Ministry of Health. First MSB Billing Number (physicians only) Add/Remove (A,R) By signing below, I confirm I: Acknowledge and have read and understand the Terms and Conditions of Use Viewed the training video Revised July 21, Page 6 of 6