Site Intake Complete this form to apply to have eChart Manitoba and/or eHealth_hub at your location. Site Intake "*" indicates required fields Step 1 of 5 – SERVICE INTEREST 20% EmailThis field is for validation purposes and should be left unchanged.SITE INFORMATIONProvide the following information about your site.Site Legal Name*Site Common Name(if different than legal)Address* Street Address City Postal Code Site Telephone Number*Site FAX NumberSite Email Address* PRIMARY CONTACT INFORMATIONThis is the person responsible for working with Digital Shared Services, Shared Health during implementation.Name* First Last Job Title / PositionTelephone Number*Site Contact Email* ADMINISTRATIVEHow would you describe your site?* Health centre Hospital / acute care Long term care and rehab Nursing station Primary care Specialty clinic Other Other Site Type(please specify)Who owns and operates your site?* Federal Fee For Service First Nations Provincial Regional Health Authority Shared Health Program Other Which Regional Health Authority?*(please choose)Interlake-Eastern RHANorthern Health RegionPrairie Mountain HealthSouthern Health-Santé SudWinnipeg RHAOther Owner or Operator's Name?* SERVICE(S) INFORMATIONPlease indicate the service(s) that you are interested in (PC)* eChart Manitoba eHealth_hub – DI eHealth_hub – Labs eHealth_hub – CR Query eHealth_hub – Enrolment eHealth_hub – Home Clinic Client Summary eHealth_hub – Immunization Query Please indicate the service(s) that you are interested in (not PC)* eChart Manitoba eHealth_hub – DI eHealth_hub – Labs eHealth_hub – CR Query eHealth_hub – Immunization Query Does your site use an EMR?* Yes No Name of EMR?NOTE: Enrolment and/or Home Clinic Client Summary services are only provisioned to a registered primary care Home Clinic. Learn about a Home Clinic at Primary Care Home Clinic | Health | Province of Manitoba (gov.mb.ca).HOME CLINICAre you currently registered as an active Home Clinic?* Yes No What is your Home Clinic name*Do you plan to become a Home Clinic?* Yes No Approximately when was the request submitted* Within the last month Within the last 6 months Within the year Have you applied to become a registered Home Clinic?* Yes No APPLICATION APPROVALAll applications must be approved by the appropriate authority for the site prior to submission (e.g. CEO, Director, President). Please indicate the name and title of that person below.Approving Authority NameApproving Authority Title
