Avon Blank Order Form - DOC

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					Application for Avon GP Organisations to access Open Exeter

All organisations must complete Parts A, B, C and Part D (d). A separate Data User
Certificate Part C must be completed for each User.


Once completed, please send to the Data Controller, Julie Cooper, Avon PCSA,
South Plaza, Marlborough Street, Bristol, BS1 3NX.


                                        ORGANISATION SECTION
PART A - PLEASE PRINT


Organisation Name        ...........................................................................

Address                  ...........................................................................

                         ...........................................................................

                         ...........................................................................

                         ..................................... Post Code …………..…

Organisation Code (L or Y number) …………………………………..


NOTE:       Your Organisation Code will be used as a unique identification code.


Primary Contact          ...........................................................................

NOTE:       (a)   The Primary Contact is important as this person will receive the user
                  names and passwords on behalf of all users.
            (b)   If the existing Primary Contact changes we require written notification
                  from the existing Primary Contact stating new person’s name,
                  telephone number and email address.

Job Title                ……………………………………………………..

Telephone No.            ...........................................................................

Fax No.                  ...........................................................................

Email address            ...........................................................................




Produced By: Avon PCSA                                                                     Date: 1 February 2010
                                                                                                     Version: 1.0
ORGANISATION SECTION
PART B


To enable access to be granted, you need to provide the reasons why you are
requesting access. Please tick any that are appropriate.


    Confirming patient/GP details
    Confirming NHS Numbers
    Verifying Patient Details
    Checking previous Breast Screening history
    Checking for cervical screening history
    Assist in Cervical Screening Programme
    Cytology – Electronic Prior Notification List & E-Cards
    Register Blood Donors
    Register Organ Donors
    Monitor GP Payments
    Check Breast Screening Status
    GP Capitation Counts
    Monitor internal use of Open Exeter
    Childhood Immunisation Returns


If not covered by any of the above, please specify:

     ..............................................................................................................................

     ..............................................................................................................................

     ..............................................................................................................................


I certify that all persons named as data users in the attached sheets have justifiable need
to access the data for reasons shown above.


Primary Contact Signature……………………………………………………………..

Date ………………………………..………….




Produced By: Avon PCSA                                                                           Date: 1 February 2010
                                                                                                           Version: 1.0
              ORGANISATION SECTION

Open Exeter Data User Certificate
(a Part C needs to be completed for the Primary Contact & one for each User)
PART C - PLEASE PRINT

Organisation Name ………………………..……..……………………..…………..

Organisation Code (L or Y Number)……………………..……………..………….

Full Name ……………….………………….………….……………………………..

Job Title……………………………….……………………………………………….

Telephone Number…………………………........................................................

E-mail Address……………………………………………………………….……….

Applications:-
 Blood Donor (Display and Update)
 Breast Screening Episodes
 Caldicott Guardian Audit Report & Statistics
 Childhood Immunisation Statements
 Cytology – Electronic Non-Responder Cards
 Cytology – Electronic Prior Notification List
 Cytology Report (essential for e-pnls & non-responder cards)
 Doctors Details
 Drug Payments
 GP Capitation Counts
 GP Payment Statements
 HPV Reports
 HPV Vaccinations
 Organ Donor (Display and Update)
 Organisation Maintenance (All Primary Contacts should request access)
 Patient Detail (with extended search)


User Signature ……………………………………….…………….Date………………………….

Primary Contact Signature ………………………………………Date………………….………

Data Controller (PCSA) Signature..……………………………..Date………….………………




Produced By: Avon PCSA                                             Date: 1 February 2010
                                                                             Version: 1.0
          EXETER SYSTEM DATA CONTROLLER SECTION
         Part 1 of 2

         PART D
PART D
  (a)
         PCT’s Exeter System:…….Avon Primary Care Support Agency ................................

         Data Controller:..…Julie Cooper .................................................................................

         Address:……PCSA, South Plaza, Marlborough Street, Bristol, BS21 3NX ................

         Telephone No:……0117 900 2418/2559………………………….

         E-mail address……Julie.Cooper@brs-pcsa.nhs.uk…………………………………

         This is to authorise connection for …………………………………… (Organisation Code)

         ---------------------------------------------------------------------------------------------------------------------------

PART D   Search Criteria to be applied & View Patient/GP Info
  (b)    (if not specified will default to YES)
                                                                                    Please circle as appropriate

         Surname and Forename only searches permitted                                      YES       NO

         Date of Birth only searches permitted                                             YES       NO

         Enable wildcard name searches                                                     YES       NO

         View Patient Address info required                                                YES       NO

         View Patient GP info required                                                     YES       NO

         Data Filters to be applied - Leaving the fields blank will mean that no filters will be
         applied.

         Sex (M/F)            …………N/A….………..                        Age Range                  …………N/A….………..

         DOB Range            …………N/A….………..                        Q Codes (up to 5) …………N/A….………..

         GP Codes             …………N/A….………..                        Partnership Code           …………N/A….………..

         PCT of Registration           …………N/A…........ PCT of Residency                        …………N/A….………..

         Organisation Code (L or Y number) …………………………………………

         Data Controller Signature……………………………………………………

         Date………………………………..…..

                                                                                                                       Continued




         Produced By: Avon PCSA                                                                Date: 1 February 2010
                                                                                                         Version: 1.0
         Part 2 of 2       Part D cont..


PART D   The following applications will be enabled for the organisation on the Open Exeter System.
  (c)    It should be noted that to access the applications the individual ‘user’ must also have
         access (part c to be completed for this).
            View Patient Detail
            Breast Screening Episodes
            Blood Donor Register (Display and Update)
            Organ Donor Register (Display and Update)
            Cytology Reports

             Electronic Prior Notification List (epnls)
             Update PNLs via browser & manual update – Notify via email

             Electronic Non-Responder Cards (e-cards)
             Update eCards via Browser & manual update – Notify via email
             Print electronic cards YES / NO*
             Women recently ceased: Enable browser view & manual update – Notify via email
             Women recently registered and currently ceased: Enable browser view & manual update – Notify via email
             First non-responder: Enable browser view & manual update – Notify via email
             Final non-responder: Enable browser view & manual update – Notify via email
             Abnormal Follow Up: Enable browser view & manual update – Notify via email
             PNL and eCards notification email address: (nhs.net address MUST be supplied)
             PNL and eCards notification CC Email:
             Allow production of HMR101 from age: 25
            GP Finance Applications (Payment Statements)
            Childhood Immunisation Statements
            GP Capitation Counts
            GP Details
            Caldicott Guardian Audit Report
            View Audit Facility

         * When you are processing using Open Exeter, cards will no longer be printed and sent to you.
PART D
  (d)    ORGANISATION SECTION
         The following information is required in order to process the application. It should be noted
         that to access the applications the individual ‘user’ must also have access (part c to be
         completed for this).

         E-mail address for e-pnls and e-cards (must be an nhs.net address as patient identifiable
         information is transferred.
         ………………………………………………………………………………………………………………..
         E-mail address to advise that GP Payment Statements are available
         ………………………………………………………………………………………………………………..
         E-mail address to advise that Childhood Immunisation Statements are available
         ………………………………………………………………………………………………………………..
         Senior Partner Local Code ……………………………………………

         Data Controller Signature……………………………………………Date……………….……………..

         Produced By: Avon PCSA                                                    Date: 1 February 2010
                                                                                             Version: 1.0
     Information to enable the completion of the
                  Application Form

GP ORGANISATIONS

Part A

An organisation wishing to obtain access to an Exeter System’s (i.e., PCT, Agency, Shared
Services) data must first complete Part A with the Organisation’s name, address, national
code and Primary Contact.

Primary Contact

The Primary Contact is important as this person will receive the user names and passwords
on behalf of all users.

When completing a new application please ensure that the Primary Contact name is the
same as on previous applications.

If the role of the existing Primary Contact changes we require written notification from the
existing Primary Contact stating new person’s name, telephone number and email address.

Part B

This must also be completed and signed by the Primary Contact.

To comply with the current Data Protection Act, an organisation must inform the Exeter
System Data Controller why access to the data is required. If your requirements are not
covered by the list in Part B, enter your reason for connection in the space provided.

Part C

An individual User Certificate must be completed for each user requiring access to the
System, including the Primary Contact, (photocopy Part C for any additional users). There
is no limit to the number of users at an organisation.

The Exeter System’s Data Controller will sign each User Certificate.

Part D

Please supply e-mail addresses to which notifications will be sent, for Cervical Screening,
Payment and Childhood Immunisation Targets shown at Part D.

The completed application can now be forwarded to the Exeter System’s Data Controller.

General

Once your application has been processed, the Primary Contact will receive an e-mail
informing them of User IDs and Passwords.




Produced By: Avon PCSA                                           Date: 1 February 2010
                                                                           Version: 1.0

				
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