Personal Care Home Registry (Pch) - Account Request Form
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1P E R SO NA L C AR E H OME R EG ISTR Y
A C C O U N T R E Q U E S T F O R M
Call the Service Desk 1-888-316-7446 (local 337-0600) if you are unclear about any fields below.
The Service Desk will complete the request within two days from receiving the request.
Return to: Fax Number: 306-781-8480
Email: servicedesk@ehealthsask.ca
User Information
Type of request (check one):
New user
Change in user type
Remove
User’s Full Name printed:
Work Phone #:
Working Title:
Email Address:
Region:
Fax Number:
Environment:
Production
Access Requested (
):
check one
View Only
Client Data Entry
Requires access to PRS?
Yes
Consultant
Home Data Entry
Ministry of Social Services (MSS) ONLY re: PCH Benefit:
Health has an Agreement in place providing disclosure through a View Only screen to MSS as a means to validate residency in a
provincially licensed care home. MSS agrees to only use this information to confirm the information provided directly from the
individual. MSS requires this information for the purposes of verifying that an applicant is resident in a licensed personal care home
and is eligible for the Personal Care Home Benefit.
View Only - the Personal Care Home Registry (PCH) – Provincial Report. This report is published monthly and is not subject to
FOIP however, the real time view is not open to the general public. MSS requires real time view in order to access the most up-to-
date information on licensed facilities. Disclosing this time sensitive information allows the individual to receive the financial top up
as soon as eligible.
P.C. Information
P.C.Location:
Facility Name:
Street Address:
City:
Province:
User’s Agreement
General Agreement
Workstation Security
•
As a user of the system, I recognize the importance of securing personal
•
I agree to keep secure all data available to me in the system.
health information.
I will not allow unauthorized users to access this
information.
•
I agree to utilize the information included in the system for the purposes
•
I will keep private all passwords associated with the system.
authorized by my Regional Executive Director or their designate.
•
I recognize that the use of this data for unauthorized or unlawful purposes
•
I have secured my workstation with a screen-saver
is strictly prohibited and is subject to prosecution by the Government of
password to assure security should I leave my machine for
Saskatchewan or its agents.
an extended period of time.
Service Authorization
User’s signature:
Date (YY/MM/DD)
I acknowledge that the subscriber is permitted access to the selected services.
Date access is required:
Date (YY/MM/DD)
Manager’s Information
Name:
(please print)
Work Phone Number
:
Signature
Date (YY/MM/DD)
Authorized Approver’s Information
Name:
(please print)
Work Phone Number
Signature:
Date (YY/MM/DD)
If you need the name of an authorized approver, please call the Service Desk 1-888-316-7446 (local 337-0600)
The most recent version of this form can be downloaded at:
May 2014
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