Community Health Practitioner PharmaNet Access Agreement

Request to Update Supervised Persons Information


* indicates field is mandatory

Practitioner College ID#*
Pharmacy Equivalency Code (PEC)
Practitioner First Name*
Practitioner Middle Name
Practitioner Surname*
Practitioner E-mail Address
Community Practice Name*
Community Practice Street Address*
Community Practice City*
Community Practice Postal Code*
Phone*
Fax
Vendor*

The Community Health Practitioner PharmaNet Access Agreement allows a practitioner to authorize persons under their direct supervision to access patient record information if the person requires this information to carry out his/her employment in the community practice.

IMPORTANT: Supervised Persons must sign an Undertaking of Confidentiality and Security by Person Accessing PharmaNet on a Practitioner's Behalf (HLTH 4531), prior to accessing patient record information. Signed Undertakings are retained by the practitioner in the community practice.


REQUEST

A. Add Supervised Person(s) to my registration information.

I authorize the following person(s) to access PharmaNet on my behalf:

Name of Supervised Person(s) Acting on my behalf

1. First Name Middle Name Surname Job Title
 
  Community Community Name
2. First Name Middle Name Surname Job Title
 
  Community Practice Name
3. First Name Middle Name Surname Job Title
 
  Community Practice Name

B. Remove Supervised Person(s) from my existing registration information.

I would like to remove the following Supervised Person(s) who currently access PharmaNet on my behalf:

Name of Supervised Person(s) acting on my behalf

1. First Name Middle Name Surname Job Title
 
  Community Practice Name
2. First Name Middle Name Surname Job Title
 
  Community Practice Name
3. First Name Middle Name Surname Job Title
 
  Community Practice Name

C. Change Name of Supervised Person on my existing registration information.

Old Name

First Name Middle Name Surname Job Title

New Name

First Name Middle Name Surname Job Title

For more information contact: HLTH.HNETConnection@gov.bc.ca


 HLTH 7094 - Last Revised: September 25, 2019