New or Updated Form

First Name

Last Name

Email

Name of ERMS form

Form Type

If using a paper form, we will ask you to send it to us when we reach out.

Adapt paper formNew digital form

Clinical/Business Value

Full Background for the Form Request

We would like to make some customisations to our pre-existing ERMS referral form to our DHB service....

Clinical Lead Approved

If Approved, please type the name of Clinical Lead

Key HealthPathways/CI/CRR contact Person

HealthPathways link

If known

Snippets Instructions

If known

Providers Receiving this Form

List of active ERMS service providers, https://provider.erms.health.nz/

Requires Triage/Reviewing

ERMS Support team will get in touch with you to discuss the details of review Criteria.

YesNo

Indicate Triage Groups Applicable for reviewing this Request

If known

General Notes

By submitting this form I acknowledge the information will be stored and processed in accordance with ERMS's privacy policy.