Cis/internet Results Service Application Form printable pdf download

CIS/Internet Results SERVICE APPLICATION FORM

Please Complete Form & Fax to 9231 4214

Or Post to St.Vincent’s Pathology, Main Building A, 41 Victoria Pde, FITZROY. 3065.

Phone: 9231 4088 / 9231 4381

Email: .au

CUSTOMER REGISTRATION INFORMATION

**PRACTITIONER / PRACTICE NAME: _____________________________________________________________________

**ADDRESS: ____________________________________________________________________________________________

____________________________________________________________________________________________

PRACTICE MANAGER/CONTACT NAME: __________________________________________________________________

TECHNICAL/COMPUTER CONTACT NAME: ________________________________________________________________

**TELEPHONE: _________________________

PAGER: ____________________

FACSIMILE: __________________

**EMAIL:

_________________________________________________________________________________________

PRACTICE DOCTORS: ____________________________________

HOSPITALS WITH ADMISSION RIGHTS: __________________________________________________________________

**COMPULSORY FIELDS**

SITE SUPPORT INFORMATION

Which of the following internet browsers will you be using?

Windows Internet Explorer

Safari

Firefox

Chrome

We require CIS for: St.Vincent’s Pathology

St Vincent’s Private Radiology

St.Vincent’s Hospital Medical Imaging Department

Please Note: Each practice staff member requiring access to this service must sign the statement below.

I hereby apply for the CIS service. I agree to comply with the Privacy Act 1988 (Commonwealth), the Health Records Act 2000

(Victoria) and any directions set down by relevant Professional Bodies concerning the electronic transmission of data.

Signature: __________________________________Date: ___________________Name: _____________________________

ONLY

INCENT

ATHOLOGY

CIS UserName: ________________ CIS Number: _________

CIS Groups: ______________________________________

PLS/RMS Entity: ________________ PLS/RMS PMIs: __________________ PLS/RMS Dr.Codes:_____________________

Other Details: ____________________________________________________________________________________________

Cis/internet Results Service Application Form