ErinoakKids Connect 16+

ErinoakKids Connect Access Request Form – 16+ ErinoakKids Client

ErinoakKids Centre for Treatment and Development’s ErinoakKids Connect Health Portal is a secure, online tool that connects you to portions of your child’s electronic health record. To request access to ErinoakKids Connect, please read this form carefully and complete the appropriate fields below. For assistance with registration, check out our instruction videos!

The following age ranges govern use of ErinoakKids Connect:

At age 16 or older: Clients can request their own access to their client’s ErinoakKids Connect record. Furthermore, the parent/guardian can retain their access to the client’s ErinoakKids Connect record unless the client 16 years or older with capacity, requests a deactivation of the parent/guardian’s access.

To request a paper copy of your record, contact the Health Records Department.

Important Notice
Please note, the client name must match what we have on file. For best results, please use the client name as it appears on your health card (if applicable). Any discrepancies may result in a delay in processing.

Client Information: (All fields required)

First Name*

Last Name*

Month of Birth*

Day of Birth*

Year of Birth*

Unit and Street Number

Address*

City*

Province*

Postal Code*

Client's Email*

Phone Number

ErinoakKids Connect User Agreement*

I Consent

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.

Name of Client*

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*