russettrehab_OHIP

RUSSETT REHABILITATION AND WELLNESS CLINIC

26 Thames Road E., Exeter, ON N0M 1S3 P: (519) 235-4892 F: (519) 235-2730
PATIENT INFORMATION
First Name
Initial
Last name
Date

MonthDayYear
Date
Preferred Name
Date of Birth

MonthDayYear
Date
Title

Dr.Mr.Ms.MissMrs.
Marital Status

singlemarrieddivorcedwidowedcommon law
Health Card Number
ODSP/OW Number
Home Address
City
Prov
Postal Code
Home Phone #
Cell Phone #
Email Address
example@example.com
EMPLOYMENT
Occupation
How long (years)
Business Name
Work Phone #
Business Address

Business Address

Street Address Line 2

City/ProvState / Province

Postal / Zip Code
Supervisor/Contact name
WSIB
Is this a WSIB claim?

YesNo
Claim #
APPROVED CLAIM?

YesNoPending
Date of accident

MonthDayYear
Date
MOTOR VEHICLE ACCIDENT
Is this a MVA claim?

YesNo
Date of accident

MonthDayYear
Date
MEDICAL DOCTOR
Family doctor's name
Address

Address

Street Address Line 2

City/ProvState / Province

Postal / Zip Code
Postal Code
Phone #
Fax
Prescribing doctor's name: Address:
Prescribing doctors name
Address

Address

Street Address Line 2

CityProvState / Province

Postal / Zip Code
Postal Code
Phone #
HospitalClinic
Site
Fax
Please enter a valid phone number.
Acceptance as Patient:

The taking of a history and the conducting of a physical examination are not considered treatment, but are part of the process of information gathering so that the practitioner can determine whether I am an appropriate patient for their services. I understand and agree that the practitioners of Russett Rehabilitation and Wellness Clinic have the right to refuse or accept me as a patient at any time before treatment begins if deemed that I am not an appropriate patient for their services.
Signature

Clear
Date

MonthDayYear
Date
Health History Form
Name
Date

MonthDayYear
Date
Area of body being assessed
List any surgeries
Please list any medications you are currently taking
Are you currently experiencing any of these symptoms?

DizzinessDouble visionTrouble speakingTrouble swallowingNight sweatsUnexplained weight loss/gain
Please check off any conditions that you have experienced.
Head/Neck

HeadachesHearing lossEarachesVision impairmentDizzinessVertigoConcussion
Respiratory

PneumoniaShortness of breathBreathing disorders(Asthma, Bronchitis)Sinus problemsSmoker
Infection

Hepatitis A,B,CTuberculosisHIV, AIDS
Cardiovascular

High blood pressureLow blood pressureVascular diseaseStrokeHigh cholesterolHeart attack/diseasePace makerCongestive heartfailureHeart valvereplacementBlood clotsHaemophilia
Women

Menstrual problemsMenopausal problemsPregnant
Pregnant : due date

MonthDayYear
Date
#of Children
Other Conditions

Crohn’s disease,Collitis, IBS, CeliacDiabetes Type I/IIGallbladder, LiverKidney, BladderThyroidEpilepsyMultiple SclerosisParkinson’s diseaseOsteoporosisOsteoarthritisRheumatoid ArthritisPsoriatic Arthritis
Ankylosing SpondylitisFibromyalgia, PMRAuto immune disease:eg. LupusLyme diseaseCollagen disease eg.Ehler- DanlosCancerMetal implants
Auto immune disease: Please specify
Collagen disease: Please specify
If cancer was selected, please specify where:
Cancer treatment
If metal implants was selected, please specify where:
Do you drink? How many per day/week?
Allergies
Mental Health

Anxiety, depressionBipolarSchizophreniaOther
Our Privacy Policy
We are committed to protecting your privacy and ensuring the confidentiality of your personal health information. The types of personal health information we collect may include your name, date of birth, health history, OHIP number and records of the care provided to you. We collect, use and disclose personal health information for the following purposes:

To provide physiotherapy, chiropractic, massage therapy and pedorthic services to our clients

To conduct quality improvement and risk management activities

To obtain payment for services provided (from you, OHIP, WSIB, auto insurance, your private insurer or others)

To comply with our regulatory obligations to College of Physiotherapists of Ontario, College of Chiropractors of Ontario, Massage therapy, pedorthic

To teach students and to provide continuing education to our staff

To advise clients about special events or opportunities (but we will always obtain express consent to do so)

For other purposes permitted by law

We will collect, use and disclose only as much personal health information as is needed to achieve these purposes. You can withhold or withdraw your consent to the collection, use or disclosure of your personal health information by contacting (details below)

Access to Health Records

You have the right to seek access to your health records that we keep and to ask us to correct a record if you believe it is inaccurate or incomplete. Please contact us for more information.

Questions or Concerns?

If you have questions or want to make a complaint about out privacy practices, please contact: LeeAnn Russett, Health Information Custodian. You also have the right to complain to the Information and Privacy Commissioner of Ontario or the address below if you have concerns about our privacy practices or how your personal health information has been handled:

Information and Privacy Commissioner/Ontario
2 Bloor Street East, Suite 1400, Toronto, Ontario M4W 1A8 Telephone: Toronto Area (416/local 905): (416) 326-3333, Long Distance: 1(800) 387-0073 (within Ontario)

TDD/TTY: (416) 325-7539 FAX: (416) 325-9195

www.ipc.on.ca
Health Consent Form

CONSENT FOR TREATMENT
I, name hereby consent to assessment and treatment by a Registered Physiotherapist/Physiotherapy Assistant (treatment only)/Registered
Chiropractor/ Registered Massage Therapist/Pedorthist, working at Russett Rehabilitation and Wellness Clinic.
I will have an opportunity to discuss with the attending registered practitioner the reasons for and nature of the treatment proposed. I was advised of the benefits, risks, side effects of the proposed treatment, the alternatives to having the treatment and what would happen if I do not have the treatment. I understand and have no further questions. My consent is voluntary.
Signature of patient

Clear
Date

MonthDayYear
Date
Printed name of patient
Signature of witness

Clear
Printed name of witness
CONSENT OF PERSONAL INFORMATION
I, name understand that to provide me with the appropriate goods and services, Russett Rehabilitation and Wellness will collect personal information about me (eg. birthdate, home contact information, health history etc.).
I have been provided the opportunity to review the Russett Rehabilitation and Wellness Clinic's Privacy Policy about the collection, use and disclosure of personal information, steps taken to protect the information and my right to review my personal information. I understand how the Privacy Policy applies to me. I have been given a chance to ask any questions about the Privacy Policies and they have been answered to my satisfaction. I understand that I can withdraw consent at any time by contacting LeeAnn Russett.

I agree to Russett Rehabilitation and Wellness Clinic collecting, using and disclosing personal health information about me as set out above and in Russett Rehabilitation and Wellness Clinic's Privacy Policy.
Signature of patient

Clear
Date

MonthDayYear
Date
Printed name of patient
PAYMENT POLICIES
Dear Patient;

Thank you for choosing Russett Rehabilitation and Wellness Clinic as your treatment facility. It is necessary that you be advised of and agree to the payment policy for our services before you begin treatment.

We accept Cash, Visa, MasterCard, Debit and Cheques as forms of payments.

PAYMENT DUE AT THE COMPLETION OF EACH APPOINMENT.

For treatment covered by WSIB or Motor Vehicle Insurance, you acknowledge that you are fully responsible for completing and submitting all necessary paperwork to the insurer to ensure timely and complete payment for rehabilitation services. If a claim is denied you will be responsible for the treatment bill. We encourage you to bring in your paperwork if you have questions regarding its completion.

If you plan to submit your receipts to an extended health insurer, please review your plan to ensure that you understand your coverage.

We kindly ask for 24 hour notice for any cancelled appointments. Cancellations received without 24 hour notice will charged 50% of service fee. Failure to provide any notice the full service fee will be charged.

Please call the clinic if unable to make an appointment and leave a message on our 24 hour answering machine, in order for us to fill that appointment.

We do understand that there are unforeseen circumstances (weather, illness, medical emergencies) these appointments will not be charged if not given 24 hours notice. In these circumstances we do request you call the clinic as soon as possible SO we can attempt to fill that appointment.

Ihave read the above information and understand and agree with the payment policy.
Signature of patient

Clear
Date

MonthDayYear
Date
Signature of witness

Clear
Date

MonthDayYear
Date
Patient Consent to Release Personal Health Information
The Ministry of Health (the “Ministry”) pays for the physiotherapy services (the “Services”) Russett Rehabilitation and Wellness Clinic (the “Clinic”) provides to you. The Ministry conducts periodic reviews to verify the Services the Clinic provided to you and to ensure the proper use of public funds.

Your Personal Health Information

To enable the Ministry to conduct its review, the Ministry needs to collect the following personal health information from the Clinic:

1. your name

2. your date of birth

3. your Ontario Health Insurance Plan number

4. your clinical record including details of your assessment, diagnosis, treatment
plan and discharge

5. the dates on which the Clinic provided Services to you

Consent for Verification Purposes

The Clinic is, therefore, asking you for your consent to allow the Ministry to collect your personal health information to assist the Ministry with its review.

Who can sign the consent form?

You can sign the consent form if:

• you are a patient of the Clinic; or

• you are a patient’s “Substitute Decision Maker” authorized under Personal Health Information Protection Act, 2004. (See more information about what this means, below).

What does “Substitute Decision Maker” mean and who is authorized under the Personal Health Information Protection Act, 2004 to act as the patient’s Substitute Decision Maker?

If a patient does not have capacity₁ to give, withhold or withdraw consent, a Substitute Decision Maker can give, withhold or withdraw consent to the collection, use and disclosure of the patient’s personal health information on behalf of the patient.

You can act as a Substitute Decision Maker for a person who does not have capacity if you have capacity and you are the highest ranked person in this list:

• a substitute decision-maker within the meaning of the Health Care Consent Act, if the collection, use or disclosure of information is connected to the decision of a substitute decision-maker about the patient’s treatment;

• the guardian of the person;

• the attorney for personal care;

• the representative appointed by the Consent and Capacity Board;

• the spouse or partner;

• a child, a parent, a children’s aid society or other person who is allowed by law to give or refuse consent in the place of the parent;

• a parent who has a right of access to the child;
• a sibling;

• a relative; or

• the Public Guardian and Trustee, if no other person meets the requirements.

Who can consent if the patient is under 16 years of age?

1. The child, so long as the child has capacity to consent,

2. A parent of the child (including a child with capacity), a member of the children’s aid society, or another person who is legally able to consent in the place of the parent except for certain situations noted below.

A child under the age of 16 who consented to their own treatment, must decide whether to consent to the collection, use or disclosure of their personal health information related to that treatment. If a child under the age of 16 has capacity to consent and disagrees with the decision of their parent (or the person legally able to consent in place of the parent), the child’s decision overrides the decision of their parent (or the person legally able to consent in place of the parent).

For clarity, there are two situations in which the parent (or other legally authorized person) cannot give consent:

1. If the personal health information relates to a treatment that a child consented to(or refused to consent);

2. If the child is capable of consenting and makes a decision about their personal health information that conflicts with the parent, or other legally authorized person’s decision.

When your consent will be effective

If you give your consent to this collection by the Ministry - either as a patient, or as Substitute Decision Maker for a patient - your consent will be effective as of the date on which you sign the consent form below.

If you choose not to consent

If you choose not to consent to this collection by the Ministry:

1. the Ministry will not pay the Clinic for the Services the Clinic provides to you or the person on whose behalf you are acting as a Substitute Decision Maker; and

2. you will be required to pay the Clinic directly for the Services.

You may withdraw your consent

If you provide your consent now you may decide to withdraw it later, but please note your withdrawal will only apply going forward and will not have any retroactive effect.
Patient Consent

I consent to the Ministry of Health collecting the following personal health information about me or the patient for whom I act as a Substitute Decision Maker (as applicable) from the Clinic for the verification purposes listed above:

1. the patient’s name

2. the patient’s date of birth

3. the patient’s Ontario Health Insurance Plan number

4. the patient’s clinical record including details of their assessment, diagnosis,treatment plan and discharge

5. the dates on which the Clinic provided Services to the patient
Signature: check one

I am signing for myself.I am signing on behalfI am signing as a Substitute Decision Maker for a person who does not have capacity.
If you are signing on behalf of as a parent, or person who is lawfully entitled to give or refuse consent, on behalf of a child who is under 16. Please list name of patient below
If you are signing as a substitute decision maker, please list name of patient below
(state appropriate description of the Substitute Decision Maker from the ranked list above, e.g.guardian of the person, attorney for personal care, spouse)
I understand that I can withdraw my consent by contacting Russett Rehabilitation and Wellness Clinic at (519) 235-4892 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.
Health Card Number
Date of Birth

MonthDayYear
Date
Name (please print)
Signature

Clear
Date

YearMonthDay
Date
Phone Number
(if you are signing on behalf of a child or as a Substitute Decision Maker for a person who does not havecapacity)
If you have questions about this consent form, please contact:

Russett Rehabilitation and Wellness Clinic
26 Thames Road East
Exeter ON N0M 1S3
(519) 235-4892

russettrehab@gmail.com
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RUSSETT REHABILITATION AND WELLNESS CLINIC

PATIENT INFORMATION

EMPLOYMENT

WSIB

MOTOR VEHICLE ACCIDENT

MEDICAL DOCTOR

Health History Form

Our Privacy Policy

Health Consent Form

PAYMENT POLICIES

Patient Consent to Release Personal Health Information