ErinoakKids - TESTING CLONE_ErinoakKids Connect

Province*

Postal Code*

Parent/Guardian Phone Number*

Parent/Guardian Email*

Siblings accessing services at ErinoakKids?*

Yes, I will have siblings accessing ErinoakKids' service. No siblings accessing ErinoakKids' service.

(If yes, a separate form is required for each child)

Parent/Guardian First Name*

Parent/Guardian Last Name*

Relationship to child*

Parent/Guardian's Day of Birth*

(Please choose a day)

Parent/Guardian's Month of Birth*

(Please choose a month)

Parent/Guardian's Year of Birth*

(Please choose a year)

Check ONLY if your address is the same as your child's address above

Address is the same

Unit and Street Number

Address

City

Province

Postal Code

ErinoakKids Connect User Agreement*

I Agree

I understand that ErinoakKids Connect is intended as a secure online source of confidential medical information and that if another individual receives my ErinoakKids Connect ID and password, he/she may be able to view my health information. I agree that it is my responsibility to select a confidential password and keep it secure. I agree that I will not share my ErinoakKids Connect ID and password. I will change my password if I believe it may have been compromised in any way. In the event I wish to provide access to ErinoakKids Connect to another individual, I will provide such individual with proxy access to my ErinoakKids Connect record. I agree that it is my responsibility to ensure that the device used for accessing ErinoakKids Connect has a current operating system (Windows, Mac) and an updated and current internet browser (e.g. Google Chrome, Internet Explorer, Firefox). I will not access ErinoakKids Connect using a public computer where I cannot be sure of the device security. I understand that ErinoakKids Connect contains selected, limited medical information from my child’s health record and that ErinoakKids Connect does not reflect the complete contents of the health record. I also understand that a paper copy of my child’s health record may be requested from ErinoakKids’ Health Records Department. I understand that my activities within ErinoakKids Connect may be tracked by computer audit and that messages I send through ErinoakKids Connect will become part of the medical record. I understand that ErinoakKids Connect access will be suspended after 24 months of inactivity. It can be reopened by visiting ErinoakKids’ Health Records Department or onsite Enrollment Station. I understand that access to ErinoakKids Connect is provided by ErinoakKids Centre for Treatment and Development as a convenience to its clients and families and that ErinoakKids has the right to deactivate access to ErinoakKids Connect at any time for any reason. I understand that use of ErinoakKids Connect is voluntary and I am not required to use ErinoakKids Connect or to authorize a ErinoakKids Connect proxy. Where applicable, I agree to designate the person named above as a ErinoakKids Connect proxy, thereby allowing them access to personal health information. I agree that ErinoakKids is not responsible for any errors contained in the information I provided on this form, or any inappropriate release of information caused by those errors. I agree that ErinoakKids may contact me electronically with information about ErinoakKids Connect or to request feedback related to my experience using ErinoakKids Connect. I agree to notify ErinoakKids immediately of any unauthorized use of my Logon ID and/or password or any other breach of security, and to ensure that I exit from my account at the end of each session. I understand that ErinoakKids will not be liable for any loss or damage arising from my failure to protect my Logon ID or password from loss or inappropriate use. I understand that ErinoakKids may use information about usage of the ErinoakKids Connect health portal for the purposes of quality improvement. I will not use ErinoakKids Connect to communicate or treat medical emergencies. If I have a medical emergency, I will call 9-1-1 immediately or go to the nearest hospital emergency department. Under no circumstances should I attempt self-treatment based on anything I’ve seen or read on ErinoakKids Connect. I understand that ErinoakKids Connect does not create physician-client relationships. The presentation of information through ErinoakKids Connect does not establish a physician-client relationship between me and ErinoakKids Centre for Treatment and Development or any of its physicians or other qualified health care providers. I understand that a client 16 years or over with capacity has the right to sever (deactivate) the portal account access of a parent or guardian, in accordance with privacy laws. I understand that ErinoakKids will not automatically deactivate proxy access for a parent or guardian unless the client requests that this access be severed. By typing my name below, I acknowledge that I have read and understand this ErinoakKids Connect Access Request Form and this User Agreement. I further acknowledge that I will read the Terms and Conditions available at online activation.

Name of Parent or Legal Guardian*

By typing my name, I acknowledge that I have read and understand this ErinoakKids Connect Access Request Form and this User Agreement. I further acknowledge that I will read the Terms and Conditions available at online activation.

Date*

Terms and Conditions of Proxy Access*

I Agree

Any information I have provided to support my right to access this client’s personal health information is true and accurately reflects my current relationship with the client. If and when my authority to access ErinoakKids Connect changes (including, but not limited, to a change in guardianship of the client, or the client or their guardian requests my removal as a proxy), I will immediately notify ErinoakKids Centre for Treatment and Development’s Health Records Department or Enrollment Advocates. I understand that my proxy request is considered effective until the client’s ErinoakKids Connect account is activated, my proxy access is revoked, or I express a wish to discontinue access. I will log into the ErinoakKids Connect service using my own ErinoakKids Connect ID and password. I understand that as a proxy, I require consent of the client to share any documents printed from ErinoakKids Connect. I will treat my log-in information and the client’s personal information as available in ErinoakKids Connect as confidential. I will not disclose it to others without the express consent of the client or their legal guardian. I understand the access to ErinoakKids Connect accounts will be terminated: If I submit an ErinoakKids Connect Deactivation Request Form The capable client decides that he/she does not wish to provide me with portal access and requests ErinoakKids sever proxy access If the legal relationship between myself and the client changes and no longer permits me the right to view his/her medical records; or if ErinoakKids determines, in its reasonable discretion, that cause exists to terminate access. By typing my name below, I acknowledge that I have read and understood the information above on ErinoakKids Connect Proxy Access and agree to these requirements.

Name of Parent or Legal Guardian*

By typing my name I acknowledge that I have read and understood the information above on ErinoakKids Connect Proxy Access and agree to these requirements.

Date*