Interdepartmental Initiative Meeting Claim Form

Name(Required)

First Last

Email Address(Required)

Mobile Number (to be contacted if there are questions about claim)

Medical Staff Type(Required)

Specialist

Are you registered with FEMS?(Required)

Yes

Do you want to be contacted for assistance with FEMS registration?(Required)

Yes

MSP Number(Required)

Meeting Name(Required)

Meeting Purpose(Required)

Meeting Date(Required)

Start Time(Required)

End Time(Required)

Number of hours claimed(Required)

Please identify the level of engagement that characterized your role in the meeting (pick only one!):(Required)

I was informed by being provided with information on an activity, project or policy

I was consulted to obtain feedback on key decisions or activities, and informed (or will be informed) of how my feedback will be used

I collaborated with decision makers to provide my advice, leadership and recommendations on a project, activity or policy

I was empowered to be a joint partner in decision-making on a project, activity or policy

General comments, and feedback for improving the meeting/ Next Steps::(Required)

Meetings initiated by physicians in non HA roles only.
Meetings focused on joint patient management on topics identified by the physician.
Dept Heads can be inivited to participate and would be compensated as long participation is not implied by reason of title or for maintenance of privelges.
Not already being reimbursed for participation via another funding source.

Please list name of the physician requesting your attendance:(Required)

Approved payments will be calculated using current GPSC/SSC sessional rates. Time rounded to nearest ¼ hour.
Approved payments will be direct deposit via LMH Facility Engagement Management System (FEMS) and Versapay. Go online to fems.facilityengagement.ca and versapay.com ; and follow instructions to enroll.
Payment will be contingent on LMH FE funding availability for this initiative in the given fiscal term.
Deadline: Claim forms must be submitted within one month of the meeting date.
Repeated (>6) meetings are asked to submit separate LMH FE Project Intent (Project Intent forms available upon request from lmhpa@facilityengagement.ca or online https://msalmh.ca/physician-engagement/facility-engagement/)

Physician Declaration

I certify that all the above criteria have been met.