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-todate 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 page 4.
SECTION A: CURRENT HSP CONTACT INFORMATION (MANDATORY)
Instructions:
Enter the information of your HSP and proceed to Section B.
HSP Full Name:
LHIN:
HSP Address:
Facility ID:
Assessment Type:
The contacts and details on this form pertain to the following assessment types for this HSP. Please identity assessment type(s) below:
Core OCAN
interRAI Preliminary Screener
interRAI CHA
For Internal Use Only
Is AEM HSP submitting assessments to the IAR?
Yes
No
Does ESP have to set up new HSP account for AEM?
(Applicable only if uploading to IAR)
Yes
No
HINP:
TransForm SSO
WOHS
HSN
SECTION B: REQUEST TYPES (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.
Information to Change
Previous 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.
New Information
HSP Full Name
LHIN
HSP Address
Facility ID
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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 – Additional Lines:
You may insert additional lines for additional users.
Request
Type
User Name
Add New
User and
Permissions
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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
Data Entry
Assessor
Supervisor
Privacy
Data Entry
Assessor
Supervisor
Privacy
2
Request
Type
Contact
Information
Type
Current Information
New Information
Name
User ID
Change
User
Information
and/or
Permissions
Not Applicable
Email
Address
Telephone
Permissions
Request
Type
Data Entry
Assessor
Supervisor
Privacy
User Name
Data Entry
Assessor
Supervisor
Privacy
User Email
User Telephone
User ID
Remove
User
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 Static IP Address
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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:


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
User Telephone
User ID
Reset User Password OR
Reactivate User Account
Reset User Password OR
Reactivate User Account
Reset User Password OR
Reactivate User Account
Reset User Password OR
Reactivate User Account
Reset User Password OR
Reactivate User Account
HSP SIGNATURES REQUIRED
HSP User Authority must sign to authorize the change.
User Authority Name
User Authority Email
User Authority Telephone
User Authority Signature
Date
Please complete this form in Microsoft Word have it signed and submit this form electronically to cmhcap@ccim.on.ca or
csscap@ccim.on.ca
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