Site Contact Update

If the individual requires access / changes to their eChart Manitoba account, please submit a completed eChart Manitoba Account and Access Request form.

Site Contact Update

Submitter Name

Submitter Email Address

eChart Site Name

Individual Information

Who is this update for?

Existing Individual

New Individual

Name

First Last

Phone

Site Contact Role(s)

(select all that apply)

All Roles Assigned Currently

Authorized Account Requestor

Authorized Sponsor

IT Resource

Outage Contact

Privacy Designate

Authorized Sponsor automatically receives monthly reports. Please indicate in the Comments section if you would like a copy of the reports sent to your Authorized Account Requestor or Privacy Designate.

Please see the Site contact roles for eChart Manitoba that provide detailed responsibilities for some of the eChart site contact roles.

Comments

Authorization: Submitting this form confirms that the individual has been authorized by the site Authorized Sponsor to fulfill the responsibilities and includes communicating with eChart Manitoba.

This field is for validation purposes and should be left unchanged.