Ministry of Health and Long Term Care

Assessment Entry Module (AEM)

HEALTH SERVICE PROVIDER AND USER ACCESS REQUEST FORM

Purpose of this Form:

  • Change Health Service Provider (HSP) contact information
  • Add, change and/or remove user accounts and permissions
  • Add and/or remove static Internet Protocol (IP) address
  • Manage password resets and reactivations

Before submitting this form for the first time, ensure an AEM Business Sustainment Roles Request Form

has been submitted and up-to-date information on individuals holding Business Sustainment Roles

has been provided to the CCIM Service Desk.

Instructions:

Step 1: Complete mandatory Section A

Step 2: Complete mandatory Section B

Step 3: Complete the subsequent applicable section(s) including required signatures and dates

Step 4: Ensure the applicable HSP signing authority signs the form on page6

SECTION A: CURRENT HSP CONTACT INFORMATION (MANDATORY)

Instructions: Enter the information for your HSP and proceed to Section B.

HSPFull Name: / LHIN:
HSPAddress: / Facility ID:

For Internal Use Only:

Does ESP have to set up new HSP account for AEM? Yes No

Is AEM HSP submitting assessments to the IAR? Yes No

(Applicable only if uploading to IAR)

HINP: TransForm SSO WOHS HSN

SECTION B: REQUEST TYPE (MANDATORY)

Instructions:

Step 1: There are four request types for managing your AEM accounts. Select one or more of the request types that apply.

Step 2:Complete the subsequent applicable section of this form.

1 / Change HSP contact information / Complete Section C
2 / Add, change and/or remove user accounts and permissions / Complete Section D
3 / Add and/or remove static IP address / Complete Section E
4 / Manage password resets and reactivations / Complete Section F

SECTION C: CHANGE HSP CONTACT INFORMATION

Instructions:

Step 1: In the “Information to change” column, indicate the change to be made.

Step 2: In the “Previous Information” column, indicate the applicable old information.

Step 3: In the “New Information” column, indicate the applicable new information.

Please be advised that the submission of this form may require follow-up to ensure the necessary details

are captured when the HSP details are changed.

Information
to change / Previous Information / New Information
HSP Full Name
LHIN
HSP Address
Facility ID

SECTION D: ADD, CHANGE AND/OR REMOVE USER ACCOUNTS AND/OR PERMISSIONS

AEM Permissions:

Data Entry – intended for non-clinical person(s) whose role is to enter assessments (from paper) into the AEM for their organization.

Assessor – intended for case workers and other personnel who conduct assessments of clients of organization.

Supervisor – intended for supervisory level positions that manage case workers. Supervisors can also conduct assessments for clients of their organization.

Privacy – intended for the organization’s Privacy Officer.

Instructions:

Step 1: In the “Request Type” column, select one or more request types that apply.

Step 2: Enter the individual’s information in the appropriate remaining columns based on the request type.Note: You may insert additional lines for additional users.

Add New Users and Permissions

User Name / User Email Address / User Telephone / AEM Permissions
Data Entry
Assessor
Supervisor
Privacy
Data Entry
Assessor
Supervisor
Privacy
Data Entry
Assessor
Supervisor
Privacy
Data Entry
Assessor
Supervisor
Privacy
Data Entry
Assessor
Supervisor
Privacy

Change User Information and/or Permissions

Contact Information Type / Current Information / New Information
Name
User ID / Not Applicable
Email Address
Telephone
Permissions / Data Entry
Assessor
Supervisor
Privacy / Data Entry
Assessor
Supervisor
Privacy

Remove User

# / User Name / User Email Address / User ID
1
2
3
4
5
6

SECTION E: ADD AND/OR REMOVE STATIC IP ADDRESS

A static external IP address is required for an HSP to access AEM. Please ensure your static IP address is an external static IP address. If you are unsure whether a static IP address is internal or external, check to see if it falls within one of the ranges listed below. If the static IP address falls within one of these numerical ranges, it is an internal IP address and cannot be used to access AEM.

  • 10.0.0.0 – 10.255.255.255
  • 172.16.0.0 – 172.32.255.255
  • 192.168.0.0 – 192.168.255.255

Instructions:

Step 1: In the “Request Type” column, indicate the type of request that applies.

Step 2: In the “IP Address” column, list the IP addresses being added or removed as applicable.

Request Type / IP Address
(Multiple IP addresses may be specified; please separate with a semicolon)
Static IP:
Add New Static IP Address
Remove Current Static IP Address

SECTION F: MANAGE PASSWORD RESETS AND REACTIVATIONS

Instructions:

Step 1: Select a separate row for each user request and indicate the request type in the “Request Type” column.

Step 2: Enter the individual’s information in the remaining columns as appropriate.

Note – Additional Lines:

You may insert additional lines for additional users

Notes for User Coordinator:

  • Users can set up secret questions in AEM to support future password recovery. This allows users to reset their passwords electronically without having to send in a reset request.
  • Passwords will expire after 90 days and must be reset at that time and account must be reactivated.

Request Type / User Name / User Email Address / User Telephone / User ID
Reset User Password and reactivate User Account
Reset User Password and reactivate User Account
Reset User Password and reactivate User Account
Reset User Password and reactivate User Account
Reset User Password and reactivate User Account
Reset User Password and reactivate User Account

HSP SIGNATURE REQUIRED

HSP User Authority must sign to authorize the change.

User Authority / Details
Name
Email Address
Telephone
Signature
Date

Please complete this form, have it signed and submit it electronically to or fax to 416-314-1585

For any questions, contact the CCIM Service Desk at 1-866-363-2246 or via email at