eGSR Version 20191006 r1

COUNTRY (CAN,USA…) *

PROV (BC,AB…) *

1. GET PERSON

LAST NAME

FIRST NAME

MIDDLE NAMES

Email *

POSTAL CODE *

Answers to – Goes By Name

1.a CREATE or UPDATE PERSON CONTACT INFORMATION

Dailing Code

Area Code

MOBILE PHONE - SMS/TEXTING Y/N

Dailing Code

Area Code

HOME PHONE

APT / UNIT

STREET NO. *

STREET NAME *

STREET TYPE (BLVD,AVE, RD, ST) *

DIRECTION (NSEW,NW,SE)

COUNTRY (CAN,USA…) *

PROV (BC,AB…) *

CITY *

POSTAL CODE *

Add Person

1.c ADD ACCOUNT

PERSONAL HEALTH NUMBER (PHN)

1.d UPDATE BIOGRAPHICAL INFORMATION

BIRTHDATE (YYYYMMDD)

1.e CREATE USER ACCOUNT (pick username & 6 character PIN)

1.e.1 VALIDATE (EMAIL & SMS) (locate message enter code)

USERNAME *

PIN CODE *

VALIDATE**

VALIDATION CODE

Add User

3. AUTHORIZATION – TO BE SIGNED BY THE PATIENT OR REPRESENTATIVE

I, the Patient or Representative named above, hereby authorize the registration of the Patient and Representative, if defined.

SIGNATURE OF CLIENT OR REPRESENTATIVE

Affiliated Organization *

DATE SIGNED(YYYYMMDD)

ESIGN CODE

GET eSign CODE**

**By clicking the [Get eSign Code]button, I acknowledge that I am signing this form electronically. The eSign transaction is logged by the system and is the legal equivalent of my handwritten signature. I will not at any time in the future claim my eSignature is not legally binding.

Get Started – Registration – Notes and Instructions: From Registration to your last “orginal” intake form. Enter information either manually or eForm registration-brochure. There are four (4) sections as follows:

(1) Client Information (Identification): Legal Name, Birthdate, Patient Health Number.

Contact information: Email Client or Guardian,Postal Code, Phone Number (Home or Cell) SMS/Texting (Y/N) [ ],Client Address.

(2) Representative – Relationship Type (Contract) is Caregiver, Power of Attorney, Guardian or a Health Representative.

Primary Relationship Role (spouse, child, parent, friend…).

(3) Notes and Questions – Service Request.
(4) Authorization – on-line forms

eForm eSignature is a text replica of a signature, validated using a eSign 8 digit code sent to a mobile phone or tablet,SMS enabled or an email address.
The transaction is logged and 8 digit code is entered beside the signature area.

*User Name is 8 to 24 characters used for “login or signin” and “secure messaging”, i.e. “username@whoknoz.me.”
A Temporary 16 character password is provided by email and should be changed a first signin session.
**Email and SMS validation and confirmation uses notification, logging and temporary passwords for validation and confirmation of eSignatures. eSIGN includes acknowledgements for PIP3 Personal Information Privacy and Protection Policy and Consent to Act as your data custodian provided to Collaborative Solutions.

Workflow

1. GET PERSON

1.a CREATE or UPDATE PERSON CONTACT INFORMATION

1.c ADD ACCOUNT

1.d UPDATE BIOGRAPHICAL INFORMATION

1.e CREATE USER ACCOUNT (pick username & 6 character PIN)

1.e.1 VALIDATE (EMAIL & SMS) (locate message enter code)

2. REPRESENTATIVE (TYPE: CAREGIVER, POWER OF ATTORNEY, LEGAL GUARDIAN, REPRESENTATIVE)

3. AUTHORIZATION – TO BE SIGNED BY THE PATIENT OR REPRESENTATIVE

Creating your own secure database instance compete with its unique encryption key. Duration ~ 30 seconds. Please Standby.

Workflow

1. GET PERSON

1.a CREATE or UPDATE PERSON CONTACT INFORMATION

1.c ADD ACCOUNT

1.d UPDATE BIOGRAPHICAL INFORMATION

1.e CREATE USER ACCOUNT (pick username & 6 character PIN) 1.e.1 VALIDATE (EMAIL & SMS) (locate message enter code)

2. REPRESENTATIVE (TYPE: CAREGIVER, POWER OF ATTORNEY, LEGAL GUARDIAN, REPRESENTATIVE)

3. AUTHORIZATION – TO BE SIGNED BY THE PATIENT OR REPRESENTATIVE

Creating your own secure database instance compete with its unique encryption key. Duration ~ 30 seconds. Please Standby.

1.e CREATE USER ACCOUNT (pick username & 6 character PIN)

1.e.1 VALIDATE (EMAIL & SMS) (locate message enter code)