Participant Consent to Release Information

Transcription

1 Participant Consent to Release Information I,, (print full name of participant or substitute decision maker) of (address) hereby authorize (name of agency serving in the role of Greater Sudbury Health Link Liaison or Lead Care Coordinator) to release and/or request the personal health information of (name of participant AND date of birth) to and/or from the following Greater Sudbury Health Link Care Team members for the purposes described below: My Greater Sudbury Health Link Care Team members Health and Social Service Providers Informal Caregivers North East Community Care Access Centre - required (NECCAC receives all GSHL referrals and stores electronic versions of all CCPs. They may also be members of Care Teams) Health Sciences North and the North Eastern Ontario Network* - required (CCPs are identified in the HSN health record in order to ensure that your care plan is available to hospital providers. They may also be members of Care Teams) Canadian Mental Health Association required (is the lead agency for the Greater Sudbury Health Link. They may also be members of Care Teams ) Consent Given (initial each agency for which consent is given) * NEON is a consortium of 21 hospital partners and 3 Independent Health Facilities serving residents of north eastern Ontario. The consortium shares an electronic health record so health care providers can better serve their patients. The full list of NEON partners can be found on the last page of this document. Page 1 of 5

2 My Greater Sudbury Health Link Care Team members, continued Health and Social Service Providers Informal Caregivers Consent Given (initial each agency for which consent is given) I understand that the Greater Sudbury Health Link (GSHL) seeks to improve the health and well-being of Sudbury residents who require multiple health and social services. As a participant in the Greater Sudbury Health Link, I will work with my full team of health and community service providers (my Care Team) to create a shared Coordinated Care Plan. In order to develop that plan and work together to achieve my goals, some information about my health, current care and treatments and personal goals will be shared amongst my Care Team. Information may also be needed to: Determine eligibility for certain services; Provide services; Evaluate the services provided to me; and Plan programs. I understand and agree to the collection, use and disclosure of personal health information with the North East Community Care Access Centre, Health Sciences North, Canadian Mental Health Association Sudbury/Manitoulin and those health and social service providers who I have identified as members of my Care Team. I understand that my Lead Care Coordinator may ask for permission to disclose some of my information to additional service providers, on my behalf, with my specific consent. I understand that the identified health and social service providers noted above will use and share my personal health information in order to develop and maintain a Coordinated Care Plan. I understand that I will be consulted during the development of this plan and a copy my Coordinated Care Plan will be provided to me. Page 2 of 5

3 I understand and agree that the GSHL and members of my Care Team will only collect, use and disclose the minimum amount of my personal health information as necessary to fulfill the purposes described above. I understand that the identified health and social service providers have established appropriate information management practices and systems to make sure that my information is shared only as necessary to fulfill the purposes described above. I also understand that I may: Withdraw consent for the sharing of personal health information by notifying my Lead Care Coordinator or any member of my Care Team; Have access to my information being held by members of my Care Team by making a request to that care provider; Forward any questions I have about my information or make a complaint if I believe that my personal health information has not been managed properly by contacting: Privacy Officer Canadian Mental Health Association Sudbury/Manitoulin 111 Elm Street, Suite 100 Sudbury, ON P3C 1T Page 3 of 5

4 I understand that this consent is valid for one year, however will be reviewed with my Lead Care Coordinator if/when changes are made to my Care Team. Use of my personal health information beyond the purposes outlined in this agreement will require my additional consent. By signing this form I do not waive any of my legal rights. Printed Name of Greater Sudbury Health Link Participant or Substitute Decision Maker Date Witness Name Participant consent achieved and confirmed by: Name Agency Date Note to Greater Sudbury Health Link Liaisons and Lead Care Coordinators: This completed document must accompany Coordinated Care Plans when they are faxed to the North East Community Care Access Centre. Note to NECCAC: This completed document must accompany Coordinated Care Plans when they are faxed to Health Sciences North for upload to the HSN Health Record. Page 4 of 5

5 North Eastern Ontario Network consortium members: Anson General Hospital, Iroquois Falls Bingham Memorial Hospital, Matheson Blind River District Health Centre, Blind River Chapleau Health Services, Chapleau Englehart & District Hospital Espanola General Hospital Hôpital Notre Dame, Hearst Health Sciences North, Sudbury Hôpital de Mattawa Hospita, Mattawa Hornepayne Community Hospital, Hornepayne Kirkland and District Hospital, Kirkland Lake Lady Dunn District Health Centre, Wawa Lady Minto Hospital, Cochrane Manitoulin Health Centre, Mindemoya and Little Current Sensenbrenner Hospital, Kapuskasing Smooth Rock Falls Hospital, Smooth Rock Falls St. Joseph s Continuing Care Centre, Sudbury St. Joseph General Hospital, Elliot Lake Temiskaming Hospital, Temiskaming Shores Timmins & District Hospital, Timmins Weeneebayko Area Health Authority, Moose Factory West Nipissing General Hospital, Sturgeon Falls Page 5 of 5