Resources & Forms

Special Access Forms

• ONTARIO CARDIAC FDG PET IMAGING REQUISITION (including sarcoidosis)

Healthcare Cath and Primary PCI Forms

Cath Referral Form

 

• Submission Instructions
• CCN Referral Form Code Definitions

Provincial Cath Referral Form for Adult Patients

Please note:

• Fax completed cath-referral form to the Regional Cardiac Care Coordinator at one of the following centres:
  
  
  • Regional Cardiac Care Coordinators Contact Information
• Do not fax the cath-referral form to the Provincial Office but directly to one of the contacts at a cardiac centre listed above.
• This form is for use by referring physicians only; referrals for cath cannot be made by patients or other non-physicians.
• This form can be used for referrals to all Ontario cath centres except those in Hamilton and Ottawa. Contact these cardiac centres directly to obtain the form used by each centre.

Forms - PLEASE FAX ALL FORMS TO REFERRAL HOSPITAL - DO NOT FAX TO CCN

• HHS Cath Referral Form
• HSN Cath Referral Form
• KGH Cath Referral Form
• LHSC Cath Referral Form
• PRHC Cath Referral Form
• RVHS Cath Referral Form
• SAH Cath Referral Form
• SHSC Cath Referral Form
• SMGH Cath Referral Form
• SMH Cath Referral Form
• SRHC Cath Referral Form
• TBRHSC Cath Referral Form
• TEGH Cath Referral Form
• THP Cath Referral Form
• UHN Cath Referral Form
• UOHI Cath Referral Form
• WOHS Cath Referral Form
• WRH Cath Referral Form
• Cath Referral Definitions
• Frequently Asked Questions regarding the CCN Referral Form

Healthcare Cath and Primary PCI Forms

Primary PCI is defined as use of PCI as the initial mode of reperfusion with STEMI

Please ensure all MANDATORY data collection fields have been completed.

You may complete optional data elements at the discretion of the CATH Lab Director.

To download a .pdf copy of the form please select the link below.

• Primary PCI Data Collection Form

CCN Registry (WTIS-CCN) Access Policy & Form
Process to obtain access:

1. Hospital Administrator must complete a New User Access Form and the User Access Agreement that corresponds to the system they would like access to (for example the CCN Registry or CRS). The forms can be found below and must be submitted to [email protected].
2. The Director, Clinical Registries will review and assess the application.
3. The Director, Clinical Registries will process application within five (5) business days.
4. Upon notification of approval of application by CCN, the following will occur:
   1. A link to the online CCN privacy training module will be sent to the applicant which must be completed prior to accessing the CCN Application
   2. A Non Disclosure Agreement (NDA) must be signed and returned to CCN.
   3. Training on the Applications will be provided through CCN (single and/or group training sessions are held throughout the calendar year at CCN or via webinars)
5. If application is not approved by CCN, notification and explanation will be provided.
6. Once privacy training is complete, the NDA has been received and the account has been created , the user will be contacted by telephone with the new username and password.
7. Once username/password is received by the applicant, the applicant should log into the CCN Application, read the license agreement and click on the agree icon.
8. CCN reserves the right to terminate end-user access in situations of misuse and/or noncompliance with the Personal Health Information Protection Act (PHIPA).

Any further questions from users can be directed to [email protected].

ONLINE FORM – – ACCESS TO CCN Registry and Custom Reporting Service

• New User Access Form
• Universe Access Agreement
• WTIS Access Agreement

Advanced Cardiac Service Hospitals Performing Minimally Invasive Procedures

• Advanced Cardiac Service Hospitals Performing Minimally Invasive Procedures

CCN Brochures

The Cardiac Care Network of Ontario makes variety of brochures available for use by both patients and families member, as well as healthcare professionals. Please select a link below for the brochures most appropriate for your use.

The following brochures and resources are designed to meet the information awareness needs of cardiac patients and physicians when navigating the cardiac care patient process.

 

To reorder CCN brochures for your hospital please click here.

• Patient Questions Regarding Access
• Patient Information Brochure
• Patient Information Brochure - French Version
• Regional Cardiac Care Coordinators
• RCCC Contact List and the Advanced Cardiac Care Patient Management Process