PART A - Pertaining to Extended Health Care Centre
I, the undersigned, hereby authorize representatives of Alliston Physiotherapy and Sports Rehabilitation to be permitted to review related records, progress reports and to discuss pertinent data with professionals involved in my rehabilitation process.
Collection, use, disclosure, security and retention of information is subject to and in compliance with the Personal Information Protection and Electronic Documents Act (please see a copy of our privacy policy) I agree that a photocopy of this authorization be accepted if necessary
Signature:
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Witness:
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Date:
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Date:
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PART B - Pertaining to Clients with Work Related and/or Motor Vehicle Injuries
I hereby authorize Alliston Physiotherapy and Sports Rehabilitation to release pertinent functional and medical information to my Doctor(s), Representatives of the Workplace Safety & Insurance Board / Representatives of Insurance Provider / Lawyer or Representatives / other Health Care Providers. In regards to Workplace Safety & Insurance Board claims, the undersigned hereby consents & authorize you to provide to my employer, periodic progress reports in the course of my treatment at Alliston Physiotherapy & Sports Rehabilitation. If required to provide progress reports, you are authorized to make reference to information that you may have in your possession which relates to my treatment. Collection, use, disclosure, security and retention of information is subject to and in compliance with the Personal Information Protection and Electronic Documents Act (please see a copy of our privacy policy) I agree that a photocopy of this authorization be accepted if necessary.
