Staff Access Request Form - Capital Health

Staff Access Request Form
eCLINICIAN Staff Access Request Form Access Completion Instructions
To be completed for each End User requesting access:
• Individual End User AHS IDs are required by Alberta Health Services (AHS) security policies for access to
eCLINICIAN. AHS logs each End User’s access electronically and these logs are monitored and audited by AHS – IT
(Information Technology). Each End User is responsible and accountable for every access against his/her End User
AHS ID. End User IDs and passwords must not be shared with other End Users.
End User Information
To be completed by the End User:
• All fields are mandatory.
• All End Users must indicate if they have attended a training session.
• All End Users must check one box to indicate the action to be taken (e.g. Create an End User AHS ID.)
• The Date of Birth, day and month only, is required for identity verification when an End User calls AHS Edmonton’s
Information Centre.
• The Secret Word and Prompt are required for End User identity verification when an End User calls AHS Edmonton’s
Information Centre.
• Remote Access Token (i.e., access from home or from a non-AHS care facility.)
- If remote access is required, each remote End User requires a remote access Token (FOB).
- If the End User has an AHS remote access Token, provide the Serial Number recorded on the back, as requested.
Existing Tokens can be used for eCLINICIAN access (new Token not required).
- If the End User does not have a remote access Token, the Remote User Network Access form must also be
completed and submitted with the Staff Access Request Form.
- Instructions on using the Token will be provided when the Token is supplied to the End User.
Access Administration
To be completed by the End User’s Site Access Administrator:
• In section D, if applicable, enter the date that the End User will no longer require access to eCLINICIAN
• Section E should be completed by the End User’s supervisor to authorize access according to the security roles
assigned in Section G (page 2)
o
The person responsible for approval, by signing the form, indicates agreement that:
• This End User performs the role and requires access (if applicable) to personal health information.
• The person signing will serve as the AHS – IT point of contact for follow up regarding this staff member
(e.g. annual review of access, access to new health information that may become available through
eCLINICIAN updates/upgrades.)
• Section H, Department/Clinic access required: This section is used to indicate which departments the End User is to
have access in, based on their workflow needs. For example, a scheduler at the RAH Fertility clinic needs access only
to the RAH Fertility clinic, whereas a pediatrician who works at the Stollery Children’s Hospital and a family practice will
need access to both departments.
End User Creation/Amendment
To be completed by the End User’s Site Access Administrator:
• Check off one security role per system (Referral, Scheduling, EMR and/or Billing) required by the End User to perform
his/her duties.
• For a detailed explanation of the security roles available, refer to the attached Security Roles chart and flowchart which
will help determine which role is appropriate for the End User based on the duties he/she is required to perform.
• For End Users requiring Billing Security, list the Physicians the End User will bill for – Table on page 3.
o List the names and emails/address.
● For listing extra Clinic Department and/or In Basket Pools please use the table on page 3.
Should a more detailed explanation of the Security Roles be required, contact your site’s Application Coordinator.

eCLINICIAN Staff Access Request Form
One SARF form per End User
End User Information eCLINICIAN training completed ? Scheduling EMR Billing
A. Physicians Only: Will Alberta Health Claims and/or Third Party billing be submitted via eCLINICIAN Billing? (Check one) Yes: No:
If Yes, eCLINICIAN will send the New Billing Physician Questionnaire and the forms to send to Alberta Health for new BA# and Submitter
Agreements upon receipt of this Staff Access Request Form.
New Non-AHS End Users call the InfoCntr 780-735-3742. The InfoCntr will assign a Request for Service to the AHS Access Admin team. This
team will send the IT Security and Compliance – Access form for completion. Upon AHS Access Admin acceptance accounts will be created.
B. All End Users:
Please check one
box and complete
the information
below
Amend End User AHS ID (Add/Change/Remove Permissions)
Create End User AHS ID -> (Email account required? Yes No)
Delete End User AHS ID for eCLINICIAN only (Token still required for Netcare access)
Delete End User AHS ID for eCLINICIAN and Netcare (Return Token – see Netcare Access Request Instructions)
Name Change
Salutation (e.g. Dr, Mr, Ms) Surname Legal First Name Middle Name
Previous Surname (for Name Change only) Preferred First Name Date of Birth
(For Unique Identification Only)
Day Month
Clinic Address City Postal Code
Gender
Female
Male
Business Phone ( ) Fax ( ) Work Email
Site
Department (Repeat in Section G for one or more Departments)
Department Role
AHS AD Login Name = (Network Login; End User AHS ID)
Secret Word – that has meaning to you (e.g. Clifford) – used for caller
verification with help desk (omit for Amend or Delete User AHS ID)
Prompt – a question (e.g. Name of my dog) used to recall your Secret Word (omit
for Amend or Delete AHS User ID)
Does this End User have a Remote Access Token? Yes No If Yes, enter Serial # (back of Token)
___________
If No, does this End User require a Token? Yes No If Yes, complete Remote User Network Access Form
Remote Computer
PC MAC Both
Current AHS Login Name (for Name Change only)
User Signature:
Access Administration
(to be completed by the site Access Administrator)
The following is required to create, amend or delete access for this End
User
C. Please complete the End User Creation/Amendments section on page 3 to assign a permission level/role to this End User.
D. If this request is to delete access, enter
date access is to be removed by: Day Month Year Token Returned: Yes No
E. I hereby authorize the creation, amendment or deletion of the End User AHS ID.
First Name Initial Surname
Site Business Phone ( )
Title
Signature/Initials
Date
Day Month Year
F. Existing eCLINICIAN End Users requiring Access to a New eCLINICIAN Department(s) /Clinic(s) Only
Please check here: Add new eCLINICIAN Dept (s) listed on page 2
End User’s Access Administrator signature: _________________________________________________________________________
Fax all forms to 780-421-8424 Access to eClinician may be refused by Alberta Health Services at its sole discretion
Version Date: Oct 2010 2

eCLINICIAN Staff Access Request Form
One SARF form per End User
Please enter the End User’s Name below to allow for form page matching should they become separated after faxing.
Salutation (e.g. Dr, Mr, Ms) Surname Legal First Name Middle Name
G. End User Creation/Amendment
Answer the two questions below. Check ONE role per system for the End User (Refer to the Security Role chart and flowcharts attached)
Will the End User see patients? Yes No Will this End User be referred to or from? Yes No
System
Security Roles
Referral Remove Access 1 2 3
Roles 1 through 3 require Basic Scheduling Training.
If no Role is checked, the Default View Only Role will be
given
Scheduling Remove Access 1 2 3 4 5 6
Roles 1 requires Super User/Overview Scheduling and Template Building Training
Roles 2 requires Super User/Overview Scheduling Training
Roles 3 & 4 require Basic Scheduling Training
EMR Remove Access
1 2 3 4 5 6 7 8 9 10
Roles 1 through 16 require EMR Training
Billing Remove Access 1 2 3 4
11 12 14 15 16 17 18 19 20
Roles 1 through 4 require Billing Training
___________________________________________________________________________________________
The columns below are for listing required access to one or multiple of the following categories:
Department names (Clinical Department Access), Physician’s names (Billing Security) and In Basket Pools.
Billing Security
Clinical Department Access
Physicians End User Bills for
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
In Basket Pools
Version Date: Oct 2010 3