1About You2Our Services3Final Step Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Phone*Please provide an phone number we can reach you at. Email* Please provide an email we can contact you at. What is your occupation?* General Practitioner / Family Physician Psychiatrist / Psychologist Specialist Nurse Practitioner Midwife Other Are you an employee of the MABC?* Yes, I am. No, I am not. What is your MABC email?* Are you an employee of the NNPBC?* Yes, I am. No, I am not. What is your NNPBC email?* Other (please specify)* Please specify the type of practice that applies to you* Walk-In Solo Shared Name of Your Practice/Organization* What is the address of your practice?* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Describe your current situation* I am continuing my practice at my current location. I am unable to continue my practice. I am acting on behalf on an individual that has passed away. I am closing / have closed my practice. I am relocating my practice. I am downsizing my practice. Please input the approx date for the practice closure, relocating, downsizing or date of passing:* Year Month Day Will you see your current patients at your new location?** Yes No Name of your NEW Practice/Clinic** Where is your NEW practice location?** Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code What would you like to do with your medical records?* I am looking to scan my paper records and require a digital copy. I am looking to store my records and provide patient access. MedRecords' Recommendation: If your records are actively being used and are required on a daily basis. We recommend choosing "scan your paper records and require a digital copy." If this is NOT true, choose the latter.MedRecords' Recommendation: Given your described situation, and based on our past interactions with other health care professionals, it is recommended to choose "storing your records and provide patient access".Do you require patient notification?*We recommend doing patients notifications that follow and adhere to College Guidelines. We can assist you with this. Yes, please help me with patient notification. No, I do not require patient notification. Is someone taking over your practice or accepting a portion of your patients?* Yes No Have multiple physicians contributed to the patients records?*A patient's record was written by multiple physicians and the record cannot be separated by physician. Yes No Have you already notified and transferred some of your patients records?* Yes, I have notified and transferred some patients records. No, I have not notified and transferred any patients records. Years in practice at your current location*Please enter a number greater than or equal to 1.What specialist services are you looking for?* I am looking to scan my paper records and require a digital copy. I need you to store my records and provide patient access. Please note: Our services are free of charge to physicians whose practices are closing and who's records will be requested by patients. Through record transfer request, MedRecords can recoup their costs. Would you like to notify your patients so they can retrieve a copy of their records?*Please be aware that sending notifications may incur extra charges (approx. $2.00 per patient). We only recommend paying for notification if ALL these situations apply to you: 1. You are the primary care provider (GP, FP, NP) 2. Your records are required to provide on-going health care. 3. Your consultation reports/notes have NOT been provided to a primary care provider. Yes, please assist me in notifying my patients. No, please do not notify my patients. What midwife services are you looking for?* I am looking to scan my paper records and require a digital copy. I need you to store my records and provide patient access. What NP services are you looking for?* I am looking to scan my paper records and require a digital copy. I need you to store my records and provide patient access. What services are you looking for?* I am looking to scan my paper records and require a digital copy. I need you to store my records and provide patient access. Do you require patient notification?*We recommend doing patients notifications if a copy of your records are required for continuity of care. We can assist you with this. Yes, please help me with patient notification. No, I do not require patient notification. Are your paper records located at the same address as previous stated?* Yes No Address of your paper records*If your paper records are NOT located at the same address as previous stated, please let us know the address. We will need this address for pick-up. Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code How many banker boxes do you have?*A banker box is measured as 15" in length. For every 15" that is 1 banker box. Refer to the scanning page for more detail.Please enter a number greater than or equal to 1.Do you require empty banker boxes?*We can ship empty banker boxes to the address provided. Please be aware that there is a charge for this service. Yes No Are there CDs and/or USBs in your patient's folders?* Yes No Do you want to take on this additional responsibility?*All physicians and health authorities are only required to store and provide copies of their own records. Yes - I would like to be responsible for someone else's medical records. Please store their information within my records. No - Please do not add other physicians' information to my records. Please discard the CDs and/or USBs. How are your paper records organized?* Alphabetical Chronological Numerical Other **Please Note** It is recommended that you comply to MedRecord's boxing guidelines or additional charges may apply for reorganization of records.Please explain in great detail how your Paper Records are organized.*Your explanation significantly assists with the transfer process for your patients. When do you require pickup of full banker boxes? (Please provide a minimum of 10 days notice)* Please provide date and time range. eg. July 3-9, 2016 from 12-5pm.What type of medical records do you have?*Check all that apply. EMR Paper Records Scanned records not stored in EMR (ie. on USB, hardrive etc) EMR Provider* Accuro OSCAR Juno Telus Health: CHR/InputHealth, MedAccess, Osler Profile/IntraHealth Plexia Ava HealthQuest MOIS Other Other (please specify)* Please Note: You will be required to inform your EMR provider that you will be closing your practice and will be requesting your records to be sent directly to MedRecords in PDF format. Please be aware there your EMR provider may charge for this service. If you use a self-host such as OSCAR, you will be required to send us your records in PDF format. You can choose any service providers to do this. We recommend Miskovic Informatics and they can be contacted directly at slobodan@miskovic.caDo you have CDs and/or USBs in your patient's folders?* Yes No Do you want to take on this additional responsibility?*All physicians and health authorities are only required to store and provide copies of their own records. Yes - I would like to be responsible for someone else's medical records. Please store their information within my records. No - Please do not add other physicians' information to my records. Please discard the CDs and/or USBs. How many banker boxes do you have?*A banker box is measured as 15" in length. For every 15" that is 1 banker box. Refer to the scanning page for more detail. Please enter a number greater than or equal to 1.Do you require empty banker boxes?*There may be an additional charge for this service. Yes No When do you require pickup of full banker boxes? (Please provide a minimum of 10 days notice)* Please provide date and time range. eg. July 3-9, 2016 from 12-5pm.Address of your paper recordsIf your paper records are NOT located at the same address as above, please let us know the address. We will need this address for pick-up. Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code How are your Paper Records organized?* Alphabetical Chronological Numerical Other **Please Note** It is recommended that you comply to MedRecord's boxing guidelines or additional charges may apply for reorganization of records.Please explain in great detail how your Paper Records are organized.*Your explanation significantly assists with the transfer process for your patients. Please provide a time frame for drop off of banker boxes (a minimum 10 days notice)* eg. After May 8, Mon-Fri from 12pm-5pmAre there any patients you DO NOT want to access your records?*Releasing these records may be detrimental to the patient's ongoing health care. In these cases, requested records will be released to their new physician. Yes (please email a CSV or Excel file to onboarding@medrecords.ca) No Comments and notesWe understand every situation is unique. Please feel free to share any additional information for our team.