I hereby consent to receive mental health and wellness services, including assessment, psychotherapy, counseling, and any other recommended treatments provided by Lusana Mental Health & Wellness Inc. (the "Clinic"). I understand that these services are designed to address my physical and/or psychological injuries resulting from a motor vehicle accident, and may include evidence-based interventions tailored to my needs.
I acknowledge that treatment involves certain risks and benefits, which have been explained to me (or will be explained as needed). I have the right to ask questions, refuse any part of the treatment, or withdraw consent at any time.
Consent for Collection, Use, and Disclosure of Personal Health Information Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA), I consent to the Clinic collecting, using, and disclosing my personal health information (PHI), including medical records, treatment notes, assessments, and reports related to my motor vehicle accident injuries, for the following purposes:
Providing and coordinating my care and treatment;
Communicating with other healthcare providers involved in my care (e.g., family physician, specialists);
Preparing and submitting treatment plans (e.g., OCF-18, OCF-23), invoices, and reports to my auto insurance company or adjuster;
Billing and processing payments for services under my accident benefits claim;
Complying with legal and regulatory requirements.
I specifically authorize the Clinic to:
Release my PHI to my auto insurance company, its adjusters, assessors, or representatives for the purpose of processing my accident benefits claim (including under the Minor Injury Guideline if applicable);
Obtain relevant PHI from other sources (e.g., prior medical records, family doctor, hospitals) as necessary for my treatment and claim;
Disclose PHI to third parties as required for claim administration (e.g., independent medical examiners, if consented separately).
I understand that:
My PHI will be protected in accordance with PHIPA and the Clinic's privacy policies;
I may withdraw or limit this consent in writing at any time (except for actions already taken); withdrawal may affect the Clinic's ability to provide services or process insurance claims;
A copy of this consent is as valid as the original.
