Hidden Briar Wellness

Patient consent form: For Collection, use and disclosure of personal information

Privacy of your personal information is an important part of our office providing you with quality massage therapy care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our clients.

In this office Robert Kingswood RMT and Robynne Kingswood RMT acts as the Privacy Information Officer for his/her clients.

All associate massage therapists who work here and who come in contact with your personal information are aware of the sensitive nature of the information you choose to disclose and are aware of the measures taken to safeguard your privacy and of the regulations that require such actions.

Below, we have outlined what our office is doing to ensure that:  Only necessary information is collected about you;  We only share information with your consent;  Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;  Our privacy protocols comply with privacy legislation, standards of our regulatory body, the College of Massage Therapists of British Columbia, and the law. We welcome your questions about our privacy policies.

PRIVACY CODE

How Our Office Collects, Uses and Discloses Patients’ Personal Information

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how our office is using and disclosing your information.

This office will collect, use and disclose information about you for the following purposes:  To deliver safe and efficient patient care  To assess your health needs  To provide appropriate health care  To advise you, the client of treatment options  To enable us to contact you to schedule or confirm appointments, distribute information about the clinic, discuss payment  To establish and maintain communications with you, the client  To communicate with other treating health-care practitioners which you will be asked to identify by name  To communicate with (named) insurance adjustors, lawyers and other support persons as is required to provide proper service to you, or as required by law and/or The Health Care Practitioners Act  To comply with Peer Assessment requirement to display for review, client files on a random basis, as required by the College  To permit potential purchasers of the practice to review the files to evaluate the practice  To invoice for goods and services  To process credit card payments (when applicable)  To collect unpaid accounts  To assist this office to comply with all regulatory requirements and to generally comply with the law

By signing the consent section of this Client Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in writing.

Your information may be accessed by regulatory authorities under the terms of the HPA for the purposes of the College of Massage Therapists of British Columbia fulfilling its mandate under the HPA, and for the defense of a legal issue.

Our office will not supply your confidential medical information to any third party without your written permission. You may withdraw your consent for use and disclosure of your personal information, and we will explain the ramifications of that decision, and the process. ______Signature Date

In order to serve you better, please indicate your wishes regarding communication and our centre.

I authorize Hidden Briar Wellness to provide reminder messages if I request by correspondence to the number I have indicated on my health history.  Yes  No

I authorize Hidden Briar Wellness to accept appointment requests, rebooking’s, cancelations and payment or provision of receipts to my spouse or other person on my behalf.  Yes  No