<p> OLIS-EMR Practice Group Profile Form</p><p>Form Completion Instructions 1. This form must be completed for each instance of an OLIS-EMR Interface requesting access to OLIS Interface. Please complete one form for each specific Practice Location. 2. All fields must be completed as specified. Mandatory fields are marked with an asterisk. Indicate “N/A” if a field is not applicable. 3. E-mail completed form to EMR Vendor.</p><p>1 – Practice Group Information (Please provide information about the Practice Group) Organization Legal Name * (e.g., Mytown Family Health Team) Location Name (e.g., Main Street Site)</p><p>Legal name change or restructuring in the last eight years? For name change, please provide previous name Yes No For legal organization restructuring, please provide summary of structure change (e.g., merger with other Practice):</p><p>Primary Business Address * (Number and Street) Suite/Unit/Floor City/Town *</p><p>Postal Code * Business Telephone * Province * Type of MOHLTC Funded Group* (e.g. FHT, FHN, FHO, Sole Practitioner etc.) </p><p>ON Total # of Physicians using EMR* Total # of Nurse Practitioners Total # of Support Staff using Affiliated LHIN* using EMR* EMR* Other Locations - If other locations share this instance of the EMR application please indicate them here </p><p>Location Location Name Name</p><p>Location Location Address Address</p><p>Business Business Telephone Telephone</p><p>2 – Lead Practitioner Name and Contact Information (Please provide information for the lead contact at the Practice) Salutation Dr. Mr. First Name * Last Name * Miss Mrs. Ms. Job Title * Business Telephone * (incl. Extension) Business Fax Business E-mail</p><p>3 – Practice Technical/IT Lead Name and Contact (Please provide the name of an technical contact who provides support for this service at the Practice Location, where different from above) Salutation Dr. Mr. First Name * Last Name * Miss Mrs. Ms. Job Title * Business Telephone * (incl. Extension) Business Fax Business E-mail</p><p>4 – Legal Signing Authority (Person with authority to bind the organisation for agreements of this kind) Salutation Dr. Mr. First Name * Last Name * Miss Mrs. Ms. Job Title * Business Telephone * (incl. Extension) Business Fax Business E-mail*</p><p>5 – Authorized Representative (Contact for notice on agreement-related matters) Salutation Dr. Mr. First Name * Last Name * Miss Mrs. Ms. </p><p>Sensitivity Level: LOW HIGH when completed Page 1 of 4 Job Title * Business Telephone * (incl. Extension) Business Fax Business E-mail*</p><p>6 – Privacy Officer or delegate (Contact for notice on privacy matters) Salutation Dr. Mr. First Name * Last Name * Job Title * Miss Mrs. Ms. Privacy Officer Address (If different from above) Suite/Unit/Floor City/Town *</p><p>Province * Postal Code * Business Telephone * (incl. Extension) Business Fax Business E-mail ON 7 – Health Information Custodian (HIC) Status Is the organization owned by one or more health care practitioners? Yes No Is the organization a Health Information Custodian under PHIPA? Yes No</p><p>8 – Organization Type Individual Practitioner Family Health Team Family Health Organization Community Health Centre Family Health Network Family Health Group Group Health Centre Aboriginal Health Centre</p><p>Nurse Practitioner Led Fee for Service Comprehensive Care Model Other (please specify): Clinic 9 – Organization Status Corporation under the Corporations Act (Ontario) Limited partnership under the Limited Partnerships Act (Ontario) Corporation under the Business Corporations Act (Ontario) Hospital under the Hospitals Act (Ontario) Partnership under the Partnerships Act (Ontario) Sole proprietorship (unincorporated) Other (Please specify):</p><p>10 – Organisation Jurisdiction Provincial If other than Ontario, please specify: Federal</p><p>11 – Vendor Information (Please provide the EMR Vendor and Software information used at this practice) EMR Vendor* EMR Software and Version Number* ABELMed Inc. ABELMed EHR-EMR/PM v12 12 – Contact Information (Please provide the name and email address of the person who completed and submitted the form to eHealth Ontario) Form Submitted By * Business E-mail * Anthony Horvath [email protected]</p><p>For Internal eHealth Ontario Use Only</p><p>Date Received: Authorized Contact Setup Date:</p><p>Unique Instance Identifier Assigned: OLIS Configuration Setup Date:</p><p>Certificate Information: ASP  Local Install  </p><p>Sensitivity Level: LOW HIGH when completed Page 2 of 4 Appendix</p><p>Sensitivity Level: LOW HIGH when completed Page 3 of 4 Clinician First Name Clinician Last Name CPSO / CNO #</p><p>Sensitivity Level: LOW HIGH when completed Page 4 of 4</p>