Governing Law and Jurisdiction Agreement
for healthcare organizations
This agreement (“Agreement”) is entered into by and between ________________________________________ and
[Name of patient]
___________________________________ (collectively, the “Parties”).
[Healthcare organization]
Governing Law
The Parties hereby agree that:
a) all aspects of the relationship between _______________________________________________ and
[Name of patient]
______________________________ (as well as her/his agents, delegates, employees, and any
[Healthcare organization]
physicians and other independent healthcare practitioners providing medical or other healthcare and
treatment to_________________________, or in association with____________________________),
[Name of patient] [Healthcare organization]
including without limitation any medical or other healthcare and treatment provided to
___________________________________, and
[Name of patient]
b) the resolution of any and all disputes arising from or in connection with that relationship, including any
disputes arising under or in connection with this Agreement,
shall be governed by and construed in accordance with the laws of the province or territory of ____________________
[Province or territory]
(other than conict of laws rules) and the laws of Canada applicable therein.
Exclusive Jurisdiction
The Parties hereby acknowledge that the medical or other healthcare and treatment received by
________________________________________from _________________________________ will be provided in the
[Name of patient] [Healthcare organization]
province or territory of______________________________, and that the Courts of ____________________________
[Province or territory] [Province or territory]
shall have exclusive jurisdiction to hear any complaint, demand, claim, proceeding or cause of action, whatsoever arising
from or in connection with that medical or other healthcare and treatment, or from any other aspect of the relationship
between ________________________________________ and ____________________________________________.
[Name of patient] [Healthcare organization]
Date: ____________________________________
_________________________________________ ___________________________________________
Name of patient [Please print] Signature of patient / substitute
decision-maker on behalf of patient
Date: ____________________________________
Per: _____________________________________ ___________________________________________
[Healthcare organization] Name [Please print)]
03/2014
Queen's Student Wellness Services
Queen's Student Wellness Services
Queen's Student Wellness Services
Ontario
Queen's Student Wellness Services
Ontario
Ontario
Queen's Student Wellness Services
Queen's Student Wellness Services
Student Wellness Services
Demographic Information
Date of Birth (YY/MM/DD):___________________
Last Name: _______________________________
Preferred name (optional):_______________________
Sex assigned at birth: M F Intersex
Preferred Pronoun (optional):_________________
Gender (optional) ___________________________
Health Card Number: __________________________ Province (health card): ___________________
Kingston Address:
____________________________________________________________________________________
Street Name & Number
Apartment
City Province Postal Code
Permanent / Family Address: (If same as above)
___________________________________________________________________________________________________________________
Street Name & Number Apartment City Province Postal Code
Phone Number: _______________________________
Can we leave a voicemail?
Yes
No
Name: ___________________________
Phone 1 #: _______________________
Relationship: ________________________________
Phone 2 #: __________________________________
_______________________________________________________________________________________
Street Name & Number
City
Prov/State Country Postal Code
Personal Information
Student #:____________________________________
First Name: __________________________________
Please Complete Reverse
Emergency Contact Information
We collect this information in the unlikely event that we would need to notify someone of a potentially life-
threatening situation, a situation in which you are unable to direct your own care, or a situation where you can not
be found. Please note that your SWS Emergency Contact information
is separate from other Emergency Contact
information you provide to the university and will not be shared with other divisions or services within the
university. As such, please ensure that your emergency contact information is updated on your Solus account.
EMERGENCY CONTACTS (preferably family or someone who you know well:
First Emergency Contact (Required)
Second Emergency Contact (Optional)
Name: ___________________________
Phone 1 #: _______________________
Relationship: _______________________________
Phone 2 #: __________________________________
_____________________________________________________________________________________________________________
Street Name & Number City Prov/State Country Postal Code
Academic Information
Faculty/School: _____________________Program:__________________________
Student Wellness Services
CONFIDENTIAL INTAKE INFORMATION
Page 2
We ask for 24 hours notice when cancelling an appointment. If you miss your appointment without cancelling,
fees will apply at the following rates
FEE
Counselling session with a COUNSELLOR/MENTAL HEALTH NURSE-----------------------------------------$30.00
10 minute PHYSICIAN appointment-----------------------------------------------------------------------------------------$30.00
20 or 30minute PHYSICIAN appointment-----------------------------------------------------------------------------------$60.00
60 minute PHYSIC
IAN/PSYCHOTHERAPY appointment--------------------------------------------------------------$120.00
20-30 minute PSYCHIATRY appointment-----------------------------------------------------------------------------------$60.00
31-60 minute PSYCHIATRY appointment-----------------------------------------------------------------------------------$120.00
61-90 minute PSYCHIATRY appointment-----------------------------------------------------------------------------------$180.00
10 minute NURSING appointment---------------------------------------------------------------------------------------------$10.00
Charges are to be paid at reception within 30 days. If payment is not received in 30 days the charges will be
applied directly to your Queen’s SOLUS account.
THIRD PARTY/UNINSURED SERVICES
Not all medical services are covered by OHIP. These include ins
urance & other form completion, driver medicals,
third party medicals, travel consultations/vaccinations, appeals, etc. Many are covered by your employer’s health
insurance plan or other 3rd party insurance plans. Patients will be advised of such charges and payment
methods. All charges for uninsured services must be settled at the point of services
SIGNATURE:
________________________________________
DATE: __________________________
This information will be used to maintain client records. All privacy regulations as per PHIPA will be abided by.
PLEASE NOTE: Student Wellness Services provides care to students currently enrolled at Queen’s University. In
other situations, please discuss with the Clinic Manager.
If you would be interested in participating in focus groups, interviews, or other similar activites to provide feedback / input on SWS
programs and services, please check the box
Yes, please contact me by email if there are opportunities
to participate
No Show Policy
Year of Study:_______
Undergraduate Student
Graduate Student
SERVICE
Professional Student
1.
2.
Full-time Student
Part-time Student
Interest Student
3.
Domestic Student
International Student
Exchange Student
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STUDENT WELLNESS SERVICES (SWS)
STUDENT EMAIL CONSENT FORM
*
Student's Name:
*
Student's Date of Birth:
*
Queen's Email:
1.
RISK
OF USING EMAIL
Risks to consider include but are not limited to:
a)
Email can be circulated, forwarded, stored, printed,
and broadcast to unintended recipients.
b)
Email senders can misaddress an email.
c)
Backup copies of email may exist even after the
sender or the recipient has deleted his or her copy.
d)
Queen's University has the right to
inspect
email transmitted
through their systems.
e)
Email can be intercepted, altered, forwarded, or
used without
authorization or detec
tion.
f)
Email can be used to introduce viruses
4.
STUDENT ACKNOWLEDGMENT AND AGREEMENT
- I understand the risks associated with the
communication of email between SWS and me.
- I understand that if I initiate contact by email, SWS
may take that as consent to reply by email to the
content of my email.
- I understand that I can choose to consent to email as a
means of contact for SWS.
- I understand the conditions and instructions outlined
here, and accept that SWS may impose other
instructions related to communicating with me by email.
- I agree to use only the pre-designated email address
specified above.
- I understand that in using Student Wellness Services,
I acknowledge that I have read, understand and accept
the practices described above.
*
Student Signature ____________________________
*
Date
_______________________________________
3.
CONDITIONS FOR THE USE OF EMAIL
SWS cannot guarantee but will use reasonable means
to
maintain security and confidentiality of email information
sent and received. The Student and SWS must consent
to the following conditions:
a)
Email is
not appropriate for urgent or emergency
situations. The Provider cannot guarantee that any
particular email will be read or responded to.
b)
Email must be concise. The Student should schedule
an
appointment to discuss the details of an issue.
c)
Email communications will be filed in the Student’s
permanent health record or departmental
file.
d)
Emails may also be delegated to another provider
or
staff member for response. Office staff may also
receive and read or respond to patient messages.
e)
E
mails sent by students will not be forwarded
outside
of
SWS without the Student’s prior written
consent, except as
authorized or required by law.
f)
Email shoud not be used for communication
regarding details of m
edical or health conditions.
g)
It is the Student’s responsibility to follow up
and /or schedule an appointment if warranted.
Revised
0
5/18
h) Medical / health advice will not be provided by email
i) SWS is not responsible for technical failures which
may preclude receipt of your emails.
* Student Number:_______________________________
*
Witness Signature___________________________
*
Date_______________________________________
5.
AUTOMATED EMAILS
SWS sends automated emails to remind students of
appointments. The automated reminders contain
information about the date and time of the student's
appointment at SWS. SWS may also send emails
with a link to provide feedback on SWS services.
These automated emails do not contain any
information about the appointment or nature of
service received.
_____(Initials) I give consent for SWS to use email as
a means of contact with me.
EMAIL COMMUNICATION
Student Wellness Services uses email to communicate
information that may be of a sensitive nature to
students. This includes information about appointment
bookings, rescheduling appointments, invoices, referral
updates, test result follow-ups, and other similar
information.
2.
_____(Initials) I do not give consent for SWS to use
email as a means of contact with me. I understand
this means I will not receive appointment reminders.
*
*
Please complete all areas that are starred (*)
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1
STATEMENTOFPRIVACY ANDCONFIDENTIALITYRE
PERSONALHEALTHINFORMATION
StudentWellnessServices (SWS)is committed to protecting your privacyandtheconfidentialnatureof
theinformationyoushare.Thisstatementoutlinesthepersonalhealthinformationpracticesweusetoprotect
yourprivacy,andyourrightsunderOntariolaw,knownasPHIPA(PersonalHealthInformationProtectionAct,
2004).Thisstatementapplies
toindividualsaccessingphysicalandmentalhealthcareservicesfromadoctor,
nurse,occupational therapist,personalcounsellor,socialworker,psychologist,psychotherapist,orpsychiatrist
atStudentWellnessServices.Pleasereviewandsign.
CollectionandUseofyourInformation
To provide you with quality health care, we keep an electronic record of information about your health
status and of the care that we have provided to you. The teamofhealth care providersatStudent
WellnessServicesusesanintegratedelectronichealthrecordto
documenttheprovisionofcare.Personal health
information is collected,used,anddisclosedbyStudentWellnessServicesaspermittedorreq uiredbylaw.
YourpersonalhealthinformationisonlytobeaccessedbyaSWShealthcareproviderorstaff memberaspart
offulfilli ngtheirjobduti esandprovidi ng
orassistingintheprovisionofhealthcare.
ConsenttoUseandShareyourInformationtoProvideYouwithHealthCare
Inalmostallcases,yourconsentisrequiredtocollect,use,anddiscloseyourpersonalhealthinformation.
Consentmeansyouareknowledgeableandinformedaboutthecollection,useanddisclosureofyour
personalhealthinformation.Consentcanbe
implied(assumed)orexplicit(verbalorwritten).
ImpliedConsent
Whenyouseekhealthcarefromus,weassumethatwehaveyourpermissiontocollect,useand
shareyourpersonalhealthinformationamongthehealthcareprovidersandadministrativestaffat
StudentWellnessServiceswhoprovideorassistin
providinghealthcaretoyou.Thesharingof
personalhealthinformationamongtheStudentWellnessServicesteamstreamlinesandenhances
thecareprovidedtoyou(e.g.adoctormayaskanursetocallyouwithlabresults;acounsellormay
consultamanageretc.)
Wealsorelyonimplied
consenttoshareyourpersonalhealthinformationona‘needtoknow’
basiswithotherhealthcareprovider soutsideofStudentWellnessServiceswhoaredirectly
involvedinyourhealthcare(e.g.faxaprescriptiontoyourpharmacist,orsendareferraltoa
specialist).
Wealsorelyon
impliedconsenttosharepersonalhealthinformationwithhealthinsurance
providers(e.g.OHIP)forbillingrelatedpurposes.
ExpressConsent
Inmostcases,yourverbalorwrittenconsentisrequiredtodisclosepersonalhealthinformationfromor
withanyonewhoisnotdirectlyinvolvedinprovidingorassistinginprovidinghealthcareservicestoyou
(e.g.afamilymember).Seebelow‐“CampusCommunity”.
2
LimitstoConfidentialityandRequirementofConsenttoReceiveorDiscloseInformation
We must also meet legal requirements to disclose personal health information in specific circumstances
withoutyourconsent(i.e.situationswhereyouarethoughttobeatriskofharmtoyourselforothers;arequest
fromalegal
authority;incasesofsuspectedchildabuse,elderabuseinalongtermcarefacility,andsexual
abusebyaRegulatedHealthCareProfessional;incaseswhenamedicalconditionsignificantlyimpairsyour
abilitytooperateamotorvehicle).
WithdrawingorRestrictingConsent(“Lockbox”)toAccesstoPersonalHealthInformation
Youhavetherighttowithdraworrestrictpartialorcompleteaccess(otherthantothosewithlegal
authorityunderPHIPA)tothepersonalhealthinformationwithinourhealthrecord.Ifyouhaveconcerns
relatedtoyourprivacyortheconfidentialityofyourinformation,pleasespeaktoyourhealthcare
provider
andwewillworkwithyoutoaddressthoseconcerns.Writteninstructionsfromyou(lockboxform)are
requiredtorestrictaccesstoyourfile.Requestingalockboxmayresultinimplicationsforyourhealth care,
andpossibleriskswillbereviewedwithyouindividuallyshouldyourequestalockboxfrom
Student
WellnessServices.
SecurityandProtectionofyourInformation
Wewilltakereasonablestepstokeepaccuraterecordsofyourhealthinformationandwillfollow alllegal
requirementsandQueen’ssecuritystandardsandbestpracticeforthesecurity,retention anddestruction
of these records. Allmedicalrecords arekeptfor
a period of time determined by themedicallicensing
authorityorotherprofessionaloversightbody.
AllhealthcareprofessionalsandadministrativestaffatSWSworkunderPHIPAandadheretotheprivacy
andsecuritypoliciesofStudentWellnessServices. If you become aware of any inappropriate use of your
personal health
information or a breach of confidentiality, please inform us immediately.UnderPHIPA,
youmayalsofileawrittencomplainttoOntario’sInformationandPrivacyCommissioner.
AccesstoyourHealthRecord
Unlessthereareunusualcircumstances,youhavetherighttoreviewand/orobtaincopiesofyour health
record.Ifaccessorcopiesareprovided,ourclinicmaychargeareasonablefeetocoverour expenses.
ChangestoyourHealthRecord
Youcanrequestachangeto
theinformationinyourhealthrecordifyouthinkthatthereisanerror oran
omissionintherecord.Thehea lthcarepractitionerwillcon sideryourrequestandeithergrantor
refuseitbasedontheirreview.Wewillplacea notationonyourhealthrecordthat yourequested
the
amendment,alongwiththedetailsofthedecisionmade.
ThirdPartyConsent
IfthereareindividualsinyourlifewhomyouwishtohaveinvolvedinyourhealthcarewhileatQueen’s,
wewillaskyoutosignaSWSConsentregardingPersonalHealthInformati onformforeachperson.Please
noteyoucanchoosewhattypeofpersonalhealthinformation
youwantustoreceiveordiscloseandyou
canwithdrawconsentatanytime.
3
CampusCommunity
StudentWellnessServicesmaybecontactedbyanindividual(e.g.parent/familymember,housemate,
friend,facultyorstaffmember,residencelife,StudentAffairs,campussecurity,chaplain)whoisconcerned
aboutyourwellbeing.Wewillco llect informationfromtheseindividualsandmayreachout toyou,as
appropriate,tofollow
upontheconcernsthathavebeenbroughttoour attention,andtoconnectyouto
supportsifneeded.Weinformtheconcernedindividualthatwemayreachouttoyou,butnoadditional
informationwillbeprovided.Pleasenotewedonotdiscloseanypersonalhealthinformationaboutyou
oryouruseofourservicesatanytime,unlessthereisbelievedtobeanimminentrisktoyoursafetyor
thesafetyofsomeoneelse.Ifyouhaveanyquestionsaboutpersonalhealthinformationprivacyand
confidentiality,youmaycontacttheClinicManagerortheuniversity’sChiefPrivacyOfficer
.
AcknowledgementandAcceptance
IacknowledgethatIhavehadtheopportunitytoreviewtheaboveStatementofPrivac yand
Confidentialityaboutmypersonalhealthinf orm ation .InusingStudentWellnessServices,Iacknowledge
thatIhaveread,understandandacceptthepracticesdescribedabove.
StudentName(pleaseprint):_______________________________________
Student
Number:________________________________________________
StudentSignature:_______________________________________________
Date:___________________________________________________________
Lastupdate:January2020
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