1. I have had all my questions answered to my satisfaction and fully understand that specific providers will either collect, use and/or disclose my personal health information. 2. I have been advised and I am aware that the following providers will collect, use and/or disclose my personal health information. 3. I have initialed the specific boxes to indicate my consent with respect to the collection, use and/or disclosure of my personal health information. Organization Name Initial Crisis Outreach and Support Team Niagara Niagara Health System I have been advised and I understand that I can withdraw my consent to the collection, use and/or disclosure of my personal health information at any time by contacting the Organizations listed on this consent. THEREFORE, HAVING REVIEWED AND FULLY UNDERSTANDING THE PURPOSE OF THIS CONSENT, I consent to the collection, use and disclosure of my personal health information to the specific providers indicated above. _______________________________ Individual Signature Print Individual Name __________________________ Signature Print Guardian / Substitute Decision Maker name, if applicable Guardian / Substitute Decision Maker Date (dd/mm/yyyy)
1. I have had all my questions answered to my satisfaction and fully understand that specific providers will either collect, use and/or disclose my personal health information. 2. I have been advised and I am aware that the following providers will collect, use and/or disclose my personal health information. 3. I have initialed the specific boxes to indicate my consent with respect to the collection, use and/or disclosure of my personal health information. Organization Name Initial Crisis Outreach and Support Team Niagara Niagara Health System I have been advised and I understand that I can withdraw my consent to the collection, use and/or disclosure of my personal health information at any time by contacting the Organizations listed on this consent. THEREFORE, HAVING REVIEWED AND FULLY UNDERSTANDING THE PURPOSE OF THIS CONSENT, I consent to the collection, use and disclosure of my personal health information to the specific providers indicated above. _______________________________ Print Individual Name Individual Signature __________________________ Print Guardian / Substitute Decision Maker name, if applicable Guardian / Substitute Decision Maker Signature Date (dd/mm/yyyy)
Niagara-CRISIS-PLAN-Template-Sept-23-2015.docx