Integrated Assessment Record (IAR) BUSINESS SUSTAINMENT ROLES REQUEST FORM Purpose of this Form: Individuals in Business Sustainment Roles at each Health Service Provider (HSP) need to be authorized either by the appropriate User Authority or Privacy Officer to allow them to manage user access to IAR and support ongoing IAR operations. This form is used to add, change, and remove information related to the HSP’s User Authority, User Coordinator, Privacy Officer, Technical Lead and Enterprise Master Patient Index Lead. Business Sustainment Role (BSR) Definitions: User Coordinator (UC) is responsible for authorizing requests for password resets and reactivations of – user accounts. User Authority (UA) is responsible for authorizing the request for new IAR Accounts or update or – removal of existing IAR accounts. Privacy Officer (PO) individual who is identified as the privacy contact on the Data Sharing Agreement – (DSA). Technical Lead/ Webservice Contact is the contact to receive upload error logs and manage – Webservice Account details. Enterprise Master Patient Index Lead (EMPI Lead) is responsible to work with the EMPI Data – Steward to resolve issues related to assessment demographic information. The User Authority and Privacy Officer must be held by different individuals. This form requires completion and submission to the CCIM Service Desk, before the CCIM Service Desk can process any HSP and user account management requests. Instructions: Step 1: Complete mandatory Section A Step 2: Complete mandatory Section B Step 3: Complete the subsequent applicable section(s) including required signatures and Step 4: Ensure the applicable User Authority and/or Privacy Officer signs the form on page 6 SECTION A: HSP INFORMATION (MANDATORY) Instructions: the information for your HSP and proceed to Section B. HSP Full Name: LHIN: HSP Address: Facility ID: For Internal Use Only: Does TransForm have to create new HSP account for EMPI set up? Yes No
Integrated Assessment Record (IAR) BUSINESS SUSTAINMENT ROLES REQUEST FORM Purpose of this Form: Individuals in Business Sustainment Roles at each Health Service Provider (HSP) need to be authorized either by the appropriate User Authority or Privacy Officer to allow them to manage user access to IAR and support ongoing IAR operations. This form is used to add, change, and remove information related to the HSP’s User Authority, User Coordinator, Privacy Officer, Technical Lead and Enterprise Master Patient Index Lead. Business Sustainment Role (BSR) Definitions: User Coordinator (UC) – is responsible for authorizing requests for password resets and reactivations of user accounts. User Authority (UA) – is responsible for authorizing the request for new IAR Accounts or update or removal of existing IAR accounts. Privacy Officer (PO) – individual who is identified as the privacy contact on the Data Sharing Agreement (DSA). Technical Lead/ Webservice Contact – is the contact to receive upload error logs and manage Webservice Account details. Enterprise Master Patient Index Lead (EMPI Lead) – is responsible to work with the EMPI Data Steward to resolve issues related to assessment demographic information. The User Authority and Privacy Officer must be held by different individuals. This form requires completion and submission to the CCIM Service Desk, before the CCIM Service Desk can process any HSP and user account management requests. Instructions: Step 1: Complete mandatory Section A Step 2: Complete mandatory Section B Step 3: Complete the subsequent applicable section(s) including required signatures and Step 4: Ensure the applicable User Authority and/or Privacy Officer signs the form on page 6 SECTION A: HSP INFORMATION (MANDATORY) Instructions: the information for your HSP and proceed to Section B. HSP Full Name: LHIN: HSP Address: Facility ID: For Internal Use Only: Does TransForm have to create new HSP account for EMPI set up? Yes No
BSRForm_AODA_IAR.docx