Electronic Update Request For Service - Early Hearing Detection and Intervention (EHDI) Program - Neonatal Intensive Care Unit Screening

Electronic Update Request - Service Profile : Early Hearing Detection and Intervention (EHDI) Program - Neonatal Intensive Care Unit Screening

If you require assistance in completing your change request, hover over the input box and a short description of the field usage will display. Inclusive language should be maintained.

Official Name

Alternate Names


EHDI (Acronym)
NICU (Acronym)

Organization

Affiliation/Partners

Short Description

Long Service Description

Key Providers May Include Check NOC List

Languages

Languages Note

Waiting Period

Waiting Time

Waiting Unit

Waiting Period Note

Referral

Referral Note

Fees

Fees Note

Fee Reduction

Fee Reduction Note

Eligibility

Eligibility Note

Eligibility Note cannot be blank since the eligibility is set to Yes.

Access

Access Note

Contact Name *

Please enter contact name.

Title

Telephone *

Please provide a phone number or email.

Email *

Please provide a valid email.

Comments

If No Changes Required to the record, select the checkbox and fill out the "Verification Contact Information" above. An email will be sent to confirm submission.

If this submission is successful, and you have provided your email address, you will receive an email confirmation.
If you do not receive this, please contact healthlink@primarycarealberta.ca