PROTECTED WHEN COMPLETED - B
Health Canada
Mental Health Counselling Appointment Confirmation Sheet
Program Billed: Indian Residential Schools - Resolution Health Support Program (IRS RHSP)
Non-Insured Health Benefits (NIHB) - Mental Health Counselling (MHC)
___________________________________ ________________________
Provider’s Signature Date (YYYY/MM/DD)
PRIVACY NOTICE
The personal information you provide to Health Canada is governed in accordance with the Privacy Act. We only collect the information
needed to administer the NIHB Program and IRS RHSP. Collection of information for this purpose is authorized under the Department
of Health Act. We require this information for the adjudication and payment of claims and for audit purposes. Your personal information
may be disclosed without your consent, but only in accordance with subsection 8(2) of the Privacy Act. For more information: This
personal information collection is described in Info Source, available online at infosource.gc.ca. Personal Information Banks (PIB) for
IRS RHSP and the NIHB Program are in development. In addition to protecting your personal information, the Privacy Act gives you the
right to request access to and correction of your personal information. For more information, please contact Health Canada / Public
Health Agency of Canada’s ATIP Coordinator at 613-954-9165 or by email at atip-aiprp@hc-sc.gc.ca. You also have the right to file a
complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly.
Please complete one form per client for sessions attended.
Client Information
Provider Information
Name:
Name:
Provider Number:
Parent or Legal Guardian Name (if applicable):
Prior Approval #:
Invoice Number:
IRS RHSP Eligibility IRSAS Verification Number:
(To be filled by Health Canada Regional Office)
Phone Number:
Email:
Date of Service
(YYYY/MM/DD)
Start Time /
End Time
Number of
Hours Used
Modality of
Session
(check one)
Client or Guardian Signature: I acknowledge receiving
counselling services indicated below
From:
To:
Face-to-Face
Telehealth
Signature:
Print Name:
Date:
From:
To:
Face-to-Face
Telehealth
Signature:
Print Name:
Date:
From:
To:
Face-to-Face
Telehealth
Signature:
Print Name:
Date:
From:
To:
Face-to-Face
Telehealth
Signature:
Print Name:
Date:
Please note that Health Canada reserves the right to request additional information if necessary to confirm the attendance.
HH:MM
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