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Completing the Initiate Home Clinic
Registration form

Download the registration form:

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If you have any questions while completing this form, call 204-926-6010, 1-866-926-6010 or email [email protected].

Complete all sections of the registration form. The section below provides additional guidance on specific areas of the form.

Part 1 – Home Clinic Information

Provide your proposed Home Clinic name. Note that it is important your Home Clinic name is both unique and meaningful. Refer to Naming your Home Clinic for guidance in determining your Home Clinic name. Include the name of the Medical Director of the clinic to support distribution of any important Home Clinic-related communications.

Indicate your Home Clinic’s primary address. If your clinic is a virtual clinic comprised of providers across various locations, designate one of the locations as the primary address.

Part 2 – Home Clinic’s Primary Contact

The Primary Contact is the Home Clinic’s single point of contact that will work closely with Shared Health’s Home Clinic team. This individual will be responsible for submitting all requests for user access to the Home Clinic Portal.

Part 3 – Electronic Medical Record (EMR) Information

Provide the name of the EMR product used by your Home Clinic providers and staff. Also indicate if the the EMR is shared (e.g. single EMR database, regional shared instance) with other practices.

Part 4 – Home Clinic Portal Users

This section is used to identify the resources from the Home Clinic that will access and maintain Home Clinic information (e.g. managing address/provider info, enrolling patients and accessing reports) via the Home Clinic Portal. Each Home Clinic should designate two resources (one as primary and one as back-up during planned or unplanned absences) as users of the portal. Provide the information for both users in this section. If the Primary Contact is a portal user, indicate by selecting the checkbox. If the user already has a Shared Health Network (NTDWRHA) user ID, this ID should be included on the form.

Saving the Form

When the form is complete, select Save As from the File menu and save to your computer. We recommend including your Home Clinic name in the file name when saving. For example, Home Clinic A Registration. Send the saved registration form to [email protected].

Next Steps

Once the user access request is processed, user credentials will be provided. At that time, you may log into the Home Clinic Portal to complete the registration process.

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