Maplecare_Wood_Patient_Consent

Patient Consent to Release Personal Health Information

The MapleCare Physiotherapy Clinic is requesting your consent to release to the Ministry of Health and Long Term Care (the “ministry”), the information you provide on this form, as well as information about the physiotherapy service(s) you receive from the physiotherapy providers in the MapleCare Physiotherapy Clinic, as of the date of your signature. The ministry requires this information to verify that the services were provided to you as a patient of the MapleCare Physiotherapy Clinic, and to pay MapleCare Physiotherapy Clinic directly for providing the services.

If you choose not to consent to the release of this information, the ministry will not pay for the services that you receive, and you will be required to pay MapleCare Physiotherapy Clinic directly for the services.

Your consent will end when:

you withdraw your consent by advising MapleCare Physiotherapy Clinic at the telephone number or address below
you no longer qualify for Ontario Health Insurance Plan (OHIP)
you cease to be a patient of the physiotherapy providers in the MapleCare
Physiotherapy Clinic

If you have questions about this consent form please call the

MapleCare Physiotherapy Clinic

at 613-691-1515

or write to:

MapleCare Physiotherapy Clinic

203-1637 Woodroffe Ave.

Ottawa ON K2G 1W2

Email: info@maplecarephysiotherapy.com

I consent to the MapleCare Physiotherapy Clinic releasing the following information to the Ministry of Health and Long-Term Care (“ministry”) as of the date indicated below:

1. Last name

First Name

Middle Name

2. Date of Birth

Date

3. My Ontario health care number

4. A description of the physiotherapy service(s) provided to me by physiotherapy providers at my physiotherapy clinic as of the date indicated below, and

5. The date(s) on which these service(s) are provided to me.

I understand that I can withdraw my consent by contacting the MapleCare Physiotherapy Clinic at 613-691-1515 and that if I withdraw my consent I will be required to pay the Clinic directly for services that the Clinic provides to me as a patient following the withdrawal of consent.

Patient Signature:

I am signing on my behalfI am signing as a parent, or person who is lawfully entitled to give or refuse consent, on behalf of a child who is under 16I am signing as the guardian of the person, or attorney for personal care of an incapable adult

Name: (please print)

Signature:

Date:

Date

Please provide your contact telephone number if you are signing on behalf of a child, or incapable adult: