I understand that CBI Health / Active Body Physical Thearpy may collect, use and disclose my personal information, including personal health information, for the purposes of:

Providing assessment, treatment or other health related services, either in person or using interactive audio, video or data communication (referred to herein as Telehealth);

Identifying treatment outcomes and the extent of health related services to be provided;

Permitting the funder (if any) to determine entitlement to my claim for compensation, benefits or insurance coverage; and

Obtaining payment for the assessment, treatment or other health related services.

I authorize CBI Health (including its personnel and authorized agents) to disclose my personal information, including personal health information, to others involved in my care, including CBI Health personnel, my healthcare providers (e.g. physician or healthcare practitioner, an allied health professional or member of my CBI Health clinical care team), payers (e.g. my insurance company or employer) and other referral sources (e.g. WorkSafe BC, WCB, WSIB, CNESST, WSNB) as reasonably necessary for such above purposes. I understand that if I am in a return to work program, CBI Health may only disclose to my employer my personal information as it relates to confirming the physical demands of my job, my functional abilities and return to work.

LIMITS TO CONFIDENTIALITY

CBI Health may disclose your personal information, including your personal health information without your consent or if you have withdrawn your consent, where permitted or required by law to do So.

For example:

• If you have been referred to, assessed or treated by CBI Health for a work-related injury (e.g. Work Safe BC, WCB, WSIB, CNESST, WNSB);
• If there is reason to believe that you are dangerous to yourself or others;
• If there is reason to believe that dependents have been or may be abused or neglected;
• If there is a medical emergency; or
• If there is a court order asking for information about your involvement with CBI Health.

PRIVACY

CBI Health is committed to collecting, using, and disclosing personal information or personal health information responsibly and only to the extent necessary for the health related services we provide. I understand that CBI Health describes its privacy practices in its Privacy Policy, a copy of which can be found at www.cbihealth.ca/privacy-policy

ELECTRONIC COMMUNICATIONS

Your information may be shared electronically between CBI Health staff in a secured network environment. CBI Health takes reasonable steps (e.g. encryption, passwords) to protect personal information that is electronically shared to permitted third parties. Such electronic communications may not be secure. Your personal or personal health information may be I acknowledge that my participation with CBI Health is accessed, collected, transmitted, stored and/or processed outside of the province in which you reside. None of your personal or personal health information will be accessed, collected, transmitted, stored and/or processed outside of Canada.

TELEHEALTH SERVICES

I understand that should I choose to accept services delivered via telehealth that a 3rd party telehealth vendor may be used and that information transmitted via telehealth will necessarily be shared with this vendor.

Telehealth allows my CBI Health clinician to consult, assess, treat and/or educate using interactive audio, video or data communication regarding my personal information. I understand that I have a right to confidentiality under the same laws that protection the confidentiality of my personal health information for in-person assessment and treatment. I further understand that there are risks unique and specific to Telehealth, including but not limited to the possibility that my sessions or other communication by CBI Health staff to others regarding my assessment or treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons. In addition, I understand that Telehealth is different from in-person healthcare services and if my CBI Health clinician believes I would be better served by another form of services, such as in-person treatment, I may be requested to attend a CBI Health location that can provide such services.

RESEARCH

I understand that from time to time, CBI Health may wish to use my personal information, including personal health information in a de-identified form to conduct research and analysis such as baseline and treatment health characteristics of persons in different groups. The results of this research and analysis will not be disclosed or otherwise published in a manner that could identify me.

I acknowledge that my participation with CBI Healthy is voluntary. I have read and fully understand and agree with the statements above.

 

I consent to the collection, use and disclosure of my personal information, including my personal health information by CBI Health (including its personnel and authorized agents I further consent to CBI Health providing me with the clinical assessment, treatment and/or other services, whether in-person or by Telehealth, related to my injury or illness, and/or my claim for compensation or benefits. The benefits, risks and results of the clinical assessment, treatment and/or other services related to my injury or illness, expected results will be explained to me by my treating clinician(s) I understand that I will be afforded the opportunity to ask my CBI Health clinician any questions I may have regarding my CBI Health assessment and treatment services and to express any concerns that I may have. I understand that I have the right to refuse or withdraw my consent in whole or in part at any time, on reasonable notice to CBI Health. If I withdraw my consent, I understand that this is not retroactive, and does not apply to personal or personal health information that has already been collected, used or disclosed by CBI Health.

I agree that CBI Health may use my email address and other contact information for the purposes of providing me with information and other communications in relation to healthcare service delivery, including virtual care and telecare and booking/confirming appointments.