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Please

fill out this Client Information Form (CIF) which includes the following information

:

• Legal Business Name
• Operating Name
• Executive Director/CEO or signing authority name and email address
• Executive Assistant Equivalent (Office Manager) name and email addressDocuments confirming your organization’s legal name (letters patent, letters of incorporation, etc.)

This form is also a self-attestation that your organization is a Health Information Custodian (HIC) under PHIPA. You must be a HIC to enter into agreement with Ontario Health.

Please include your letters patent, incorporation documents, or name change documents along with this form to confirm your legal name.

You must select a CMS vendor through your organization’s procurement process. Please see below the CMS’ The following CMS applications are eligible for the one-time funding opportunity:

• CRMS
• VitalHub Treat
• Vitalhub CaseWORKS
• EMHWare

Once you choose a vendor, you must submit an itemized quote for the full and final cost of the migration.

Examples of vendor costs to be reimbursed by One-Time Funding Opportunity

• One year licensing, subscription or maintenance fee
• Data Migration / Data Transfer (can include cost/invoice from current vendor system & cost of migration to new system)
  *please note that you will be required to submit an invoice from your current vendor and new vendor if applicable
• User Licenses / Software Licenses
• Training
• Office 365 Integration
• MHA Applicable Modules
• Configuration
• Vendor supports.

Examples of vendor costs that are not eligible for one-time funding

• Ongoing licensing/subscription fees
• Purchasing of new software or equipment unrelated to the CMS migration (e.g. Microsoft 365, computers)
• Custom reporting outside the scope of MHA.

The completed Client Information Form and Quotes must be submitted via your existing Expression of Interest ticket on the Mental Health and Addictions Provincial Data Set (PDS) Service Desk (for step-by-step instructions on how to attach files to a ticket, go to the  bottom of this page). Quotes will be accepted between November 11^th, 2024 and January 6^th, 2025. Funds will be allocated on a first come, first serve basis until the pool of funds is exhausted.

OH will confirm the final funding amount to be allocated to the HSP within 3-5 business days of receipt of the quote submission. 

If you have any questions, please submit them via your existing Expression of Interest ticket.

Click on the Add a comment… text in the comment field at the top of the ticket to expose the field editing toolbar. 

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Click on the Attachment button under the field to attach a file from your computer. 

Add some text to the comment: this will enable the Post Comment button.

When finished, click Post Comment to post the comment and attached file(s) to the ticket.