FHO Enrolment & Consent to Release Personal Health Information

Patient Enrolment and Consent to Release Personal Health Information
One form per adult patient. Photocopy for additional adult family members.
Collection of the information on this form is under the authority of the Ministry of Health Act, subsection 6(1) and (2) and the Health Insurance Act R.S.O. 1990, c. H.6, s.4(2)(b) and (f), 4.1(1) and (2), 10 and 11(1). For information about collection practices, contact the Director, Registration and Claims Branch, Box 48, 49 Place d'Armes, Kingston ON K7L 5J3, INFOline tel 1 888 218-9629 or by mail through the addresses listed for local Ministry of Health and Long-Term Care offices.
Section 1 I want to enrol myself with the family doctor identified in Section 4
Name

First NameSecond NameLast Name
Health Number
Version Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth (yyyy/mm/dd)

MonthDayYear
Date
MF
Residence Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
regular mailemail (if possible)
mailing address
Email Address:
example@example.com
Section 2 I want to enrol my child(ren) under 16 and/or dependent adult(s) with the family doctor identified in Section 4
Child #1

First NameMiddle InitialLast Name
Health Number
Version Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth (yyyy/mm/dd)

MonthDayYear
Date
MF
same as Section 1
parentlegal guardianattorney for personal care
Residence Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
same as Section 1
Child #2

First NameLast Name
Health Number
Version Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth (yyyy/mm/dd)

MonthDayYear
Date
MF
Section 1
parentlegal guardianattorney for personal care
Residence Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
same as Section 1
Section 3 Signature
I have read and agree to the Patient Commitment, the Consent to Release Personal Health Information and the Cancellation Conditions on the back of this form. I acknowledge that this Enrolment is not intended to be a legally binding contract and is not intended to give rise to any new legal obligations between my family doctor and me.
Section 4 Family doctor information
Dr. Samuel Onuekwa
Harvester Road FHO

Bellcrest Family Clinic
Unit 407-672 Brant Street
Burlington, Ontario L7R 2H3

Phone: 289-245-1071

Fax: 289-245-1486
myselfchild(ren)dependent adult(s)
My Name

First NameLast Name
Signature

Clear
Date (yyyy/mm/dd)

MonthDayYear
Date
Home Telephone No.
Format: (000) 000-0000.
Work Telephone No.
Format: (000) 000-0000.
Should be Empty:

Patient Enrolment and Consent to Release Personal Health Information

Section 1 I want to enrol myself with the family doctor identified in Section 4

Section 2 I want to enrol my child(ren) under 16 and/or dependent adult(s) with the family doctor identified in Section 4

Section 3 Signature

Section 4 Family doctor information