HA – Register

Dear Patient,

According to our records, you completed our email consent form below previously. Please review and reaffirm your consent and email address.

This clinic supports the use of email for the purpose of communicating with our patients regarding their clinical care. A care provider may agree to communicate with you using email but is not required to do so. You may choose to communicate with the clinic using email but you are not required to do so.

If you choose use email at the clinic, signing this consent form provides the clinic with your permission to communicate with you via email and is required before we will respond to your email or send you email for the first time. This consent can be withdrawn at any time by contacting the clinic by phone or in person.

If you choose to communicate with the clinic using email, you should be aware that email messages you send to or receive from the clinic:

• may not be secure. The clinic cannot guarantee the security of any email message transmitted outside of our email system;
• may exist as an electronic or paper record within the clinic indefinitely.

For these reasons, if you use email to communicate any information, including personal health information, to the clinic, or to receive any information, you are hereby accepting the inherent risk of this information being compromised.

THE CLINIC CANNOT GUARANTEE THAT YOUR EMAIL WILL BE RECEIVED, READ OR RESPONDED TO WITHIN ANY PARTICULAR PERIOD OF TIME. YOU MUST NOT COMMUNICATE WITH THE CLINIC VIA EMAIL FOR MEDICAL EMERGENCIES OR OTHER TIME-SENSITIVE MATTERS.

TERMS OF USE
I understand that it is my responsibility to monitor email received at the indicated email address(es) and to advise the clinic in writing if any email address changes or should no longer be used by the clinic for email communications with myself. I understand that only this email address will be used by the clinic for communication to me.
If I am signing on behalf of my minor child, I understand that when he/she turns 16 this consent will be void and the child will have the option of signing his/her own consent for ongoing email communication with the clinic.
I understand that the clinic cannot guarantee the security of email messages that I send to or receive from the clinic.
I agree not to use email to communicate emergency or urgent information about myself and understand that the clinic does not guarantee the receipt or review of any email messages that I may send to the clinic.
I understand and agree that individual care providers may make decisions about my treatment based on information I provide through email and that this information may form part of my health record.
I understand that I may stop using email for clinical communication purposes at any time, at which point I will notify the clinic in writing of my decision to stop using email for these purposes. I understand that this consent remains effective unless and until it is withdrawn.
I understand that individual care providers may stop using email for clinical communication purposes at any time, at which point s/he will inform me in writing or notify me about this decision at the time of my next appointment.
Consent for Patients Over Age 16
I, confirm that I have read and agree to these terms and I wish to communicate with the clinic via email for the purposes of my clinical care.

Ministry of Health and Long-Term Care

Patient Enrolment and Consent to Release Personal Health Information

Patient Commitment
I agree to contact my family doctor (or if applicable the group to which my family doctor belongs or the designated Telephone Health Advisory Service if available to me), when I, or my enrolled child(ren) or dependent adult(s), need primary care medical advice or treatment. I promise to do this unless there is an emergency or I am travelling away from home.
I agree that if I or the person(s) I have signed for move, I will contact my family doctor’s office or the ministry (see box below) with a new address and telephone number.
I understand that I can end my enrolment with this family doctor and enrol with another family doctor after six weeks have passed from the date that I complete and sign this form (immediately if I have moved). However, I agree not to change the doctor with whom I am enrolled more than twice a year.
I understand that by enrolling a child under 16 or a dependent adult, my signature on the front of this form means that I agree to these terms and conditions on behalf of that person. When an enrolled child reaches 16 years of age, the ministry will contract him or her to confirm enrolment/consent with the family doctor.

Consent to Release Personal Health Information
I understand that my family doctor will be able to offer better medical care if I permit my family doctor and the ministry to share appropriate and relevant information relating to my health.
I agree to allow my family doctor, other family doctors in the Patient Enrolment Model (if applicable) and the ministry to exchange the information in this form related to my enrolment.
I agree that my family doctor and the ministry can exchange information about my name, address and telephone number.
I agree to allow the ministry to release the following specific information to my family doctor:
-date of immunizations (flu shots, etc.)
-dates of preventative care screening services (pap tests, mammograms, etc.)
-dates of service, fees paid and fee codes of primary health care services provided to me by a family doctor outside by family doctor’s Patient Enrolment Model (if applicable).
If the Telephone Health Advisory Service is available to me, I agree to allow my family doctor and the ministry to exchange only the following information with the designated Telephone Health Advisory Service: my name, health number and version code, address, date of birth, gender.
I understand that this consent to release personal health information ends when:
-My enrolment with my family doctor ends or
-I cancel my consent by writing or telephoning the Ministry of Health and Long-Term Care (see box below).
The ministry will inform my family doctor when the consent is no longer valid. However, I understand that the information already released to my family doctor will remain in my medical file.

Cancellation Conditions
Enrolment with my family doctor and my consent to release personal health information will end when:

1. I cancel my enrolment by writing or telephoning the ministry (see box below);
2. I no longer qualify for health care services under the Health Insurance Act (Ontario);
   c) the Patient Enrolment Model to which my doctor belongs no longer exists;
   d) my family doctor chooses to discontinue acting as my family doctor in accordance with the College of Physicians and Surgeons of Ontario guidelines;
   e) I enrol with another family doctor; or
   f) the ministry grants me an extended absence.
   
   My enrolment with my family doctor and my consent to release personal information may end when:
3. I consistently fail to meet the obligations to which I agreed in the Patient Commitment (above);
4. My family doctor leaves this Patient Enrolment Model;
5. I become a resident of a long-term care facility;
6. I am imprisoned in a provincial or federal correctional institution; or
7. I move outside the geographic area where the Patient Enrolment Model to which my family doctor belongs regularly provides services.
   
   Contact Information:
   Ministry of Health and Long-Term Care
   P.O. Box 48, Station Main
   Kingston, ON K7L 9Z9
   Call: INFOline 1 888 218-9929
   TTY 1 800 387-5559

Collection of the information on this form is under the authority of the Ministry of Health Act, subsection 6(1) and (2) and the Health Insurance Act, R.S.O. 1990, c. H.6, s.4(2)(b) and (f), 4.1(1) and (2), 10 and 11(1). For information about collection practices, contact the Director, Registration and Claims Branch, Box 48, 49 Place d’Armes, Kingston ON K7L 5J3, INFOline tel. 1888 218-9929 or by mail through the address listed for local Ministry of Health and Long-Term Care offices