MD Connected Family Health Registration

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 contact 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:

- dates of immunizations (flu shots, etc.)

- dates of preventive 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 my 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:

- I cancel my enrolment by writing my family doctor or by writing or telephoning the ministry (see box below);

- I no longer qualify for health care services under the Health Insurance Act (Ontario);

- the Patient Enrolment Model to which my doctor belongs no longer exists;

- my family doctor chooses to discontinue acting as my family doctor in accordance with the College of Physicians and Surgeons of Ontario guidelines;

- I enrol with another family doctor; or the ministry grants me an extended absence.

My enrolment with my family doctor and my consent to release personal health information may end when:

- I consistently fail to meet the obligations to which I agreed in the Patient Commitment (above);

- my family doctor leaves this Patient Enrolment Model;

- I become a resident of a long-term care facility;

- I am imprisoned in a provincial or federal correctional institution; or

- 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 929

Call: INFOline: 1 888 218-9929

TTY: 1 800 387-5559