Disclosure Authorization Consent Form

In today’s world, it is common for a spouse or partner to arrange appointments for their family members, or for a parent or guardian to assist with the health care needs of adult family members.  However, it is not permissible for a spouse to act on their spouse’s behalf, or a parent/guardian on behalf of a patient that has aged out of pediatric consent, age 14 and over, unless authorized

Pursuant to the Personal Health Information Act, 2004 (PHIPA), the form below is for the purpose of authorizing someone other than yourself to communicate with our staff with regard to your medical information (see page 2 for details).  This form can be completed at your convenience and the original submitted at either the Erin or Rockwood clinic.  Please note that you may be contacted to verify the authenticity of your consent if someone, other than yourself, delivers this form. 

Alternatively, you may contact us by phone (Erin: 519-833-9396 or Rockwood: 519-856-4611) and ask that your verbal consent be documented in your chart.  If you choose the phone-in option, staff will explain to you what your consent means and how it will be carried out.

If you have given us permission to share your health information with someone, i.e. family or friend, please know that this consent remains in your chart until you instruct us otherwise.  If you would like to remove this permission, please speak with your doctor or reception staff.

Transfer of Records

To expedite the transfer of your medical records, please complete one of the following forms:

For all Medical Records inquiries, requests and form submissions CLICK HERE

Moving away and need a new doctor?   

Health Care Connect refers Ontarians who don't have a physician to a family health care provider who may be accepting new patients.  You can only join Health Care Connect if you don’t have a family health care provider. If you would like to use Health Care Connect to switch to a new family health care provider, you must first take yourself off the patient list of your current one. There are two ways to do this:

 Click here for more information.

Patient Rights & Responsibilities

As a patient, you are responsible for:

Should a breach of any of these responsibilities occur, depending on the severity of the actions, any or all of the following may be carried out:

As a patient, you have the right to:

Providing Feedback:

We ask patients or families who have problems, complaints or concerns to follow the process described below. These steps ensure patients first seek assistance from staff members who are most familiar with their care, and who can provide additional options if needed:

  1. Please speak with the members of your healthcare team first. Usually, they can quickly resolve most issues.
  2. If you are not satisfied with the response you have received from your healthcare team, you can contact us here with attention EWFHT Management Team.  Alternatively, you may call (519) 833-9396.  In order for the Management Team to investigate the complaint, it must be made in writing and either e-mailed to the above address or mailed to EWFHT, 6 Thompson Crescent, Unit 1, Erin, ON N0B 1T0, Attention:  Executive Director.
  3. Receipt of your written complaint will be acknowledged within 5-7 business days.
  4. The situation with which you are dissatisfied will be investigated and findings will be communicated back to you within four weeks unless otherwise notified, i.e. timelines may be impacted by staff vacations, statutory holidays, etc.

Printable Version

Privacy Policy

Commitment to Privacy

Protecting your privacy and the confidentiality of your personal information has always been an important aspect of the East Wellington Family Health Team (EWFHT) operations. The appropriate collection, use, and disclosure of patients’ personal health information are fundamental to our day-to-day operations and to your care. We strive to provide you with excellent medical care and service, which includes treating your personal information with respect. Each member and employee of the practice must abide by our commitment to privacy in the handling of personal information.

Applicability of This Privacy Policy

Our Privacy Policy informs you of our commitment to privacy and tells you the ways we ensure that your privacy is protected. Our Privacy Policy applies to protect the personal health information of all our patients that are in our possession and control.

What is Personal Health Information?

Personal health information means identifying information about an individual relating to their physical or mental health (including medical history), the providing of health care to the individual, payments or eligibility for health care, organ and tissue donation and health number.

The 10 Principles of Privacy

Our Privacy Policy reflects our compliance with fair information practices, applicable laws and standards of practice.

1. Accountability

We take our commitment to securing your privacy very seriously. Each physician and employee associated with the EWFHT is responsible for the personal information under his/her control. Our employees are informed about the importance of privacy and receive information periodically to update them about our Privacy Policy and related issues. In addition to establishing this Privacy Policy, we have appointed our Executive Director as the person responsible for all privacy matters.

2. Identifying Purposes: Why We Collect Information

We ask you for information to establish a relationship and serve your medical needs. We obtain most of our information about you directly from you, or from other health practitioners whom you have seen and authorized to disclose to us. You are entitled to know how we use your information and this is described in the Privacy Statement posted at the end of this document. We will limit the information we collect to what we need for those purposes, and we will use it only for those purposes. We will obtain your consent if we wish to use your information for any other purpose.

3. Consent

You have the right to determine how your personal health information is used and disclosed. For most health care purposes, your consent is implied as a result of your consent to treatment, however, in some circumstances your express, sometimes written, consent may be required.EWFHT Privacy Policy updated May 2012

4. Limiting Collection

We collect information by fair and lawful means and collect only that information which may be necessary for purposes related to the provision of your medical care.

5. Limiting Use, Disclosure, and Retention

The information we request from you is used for the purposes defined. We will seek your consent before using the information for purposes beyond the scope of the posted Privacy Statement. Under no circumstances do we sell patient lists or other personal information to third parties. There are some types of disclosure of your personal health information that may occur as part of the EWFHT fulfilling its routine obligations and/or clinical management. This includes consultants and suppliers to the Practice, on the understanding that they abide by our Privacy Policy, and only to the extent necessary to allow them to provide business services or support to this Practice. We will retain your information only for the time it is required for the purposes we describe and once your personal information is no longer required, it will be destroyed. However, due to our ongoing exposure to potential claims, some information is kept for a longer period. Medical records are kept for at least 10 years.

6. Accuracy

We endeavor to ensure that all decisions involving your personal information are based on accurate and timely information. While we will do our best to base our decisions on accurate information, we rely on you to disclose all material information and to inform us of any relevant changes.

7. Safeguards: Protecting Your Information

We protect your information with appropriate safeguards and security measures. The EWFHT maintains personal information in a combination of paper and electronic files. Recent paper records concerning individuals’ personal information are stored in files kept onsite at our Erin Clinical office. Access to personal information will be authorized only for the physicians and employees associated with the EWFHT, and other agents who require access in the performance of their duties, and to those otherwise authorized by law. We provide information to health care providers acting on your behalf, on the understanding that they are also bound by law and ethics to safeguard your privacy. Other organizations and agents must agree to abide by our Privacy Policy and may be asked to sign contracts to that effect. We will give them only the information necessary to perform the services for which they are engaged, and will require that they not store, use or disclose the information for purposes other than to carry out those services. Our computer systems are password-secured and constructed in such a way that only authorized individuals can access secure systems and databases. If you send us an e-mail message that includes personal information, such as your name included in the “address”, we will use that information to respond to your inquiry. Please remember that e-mail is not necessarily secure against interception. If your communication is very sensitive, you should not send it electronically unless the e-mail is encrypted or your browser indicates that the access is secure.

8. Openness: Keeping You Informed

The EWFHT has prepared this plain-language Privacy Policy to keep you informed. You may ask to receive a copy of it from any of the front desk receptionists. If you have any additional questions or concerns about privacy, we invite you to contact us and we will address your concerns to the best of our ability. EWFHT Privacy Policy updated May 2012

9. Access and Correction

With limited exceptions, we will give you access to the information we retain about you within a reasonable time, upon presentation of a written request and satisfactory identification. We may charge you a fee for this service and if so, we will give you notice in advance of processing your request. If you find errors of fact in your personal health information, please notify us as soon as possible and we will make the appropriate corrections. We are not required to correct information relating to clinical observations or opinions made in good faith. You have a right to append a short statement of disagreement to your record if we refuse to make a requested change. If we deny your request for access to your personal information, we will advise you in writing of the reason for the refusal and you may then challenge our decision.

10. Challenging Compliance

We encourage you to contact us with any questions or concerns you might have about your privacy or our Privacy Policy. We will investigate and respond to your concerns about any aspect of our handling of your information. In most cases, an issue is resolved simply by telling us about it and discussing it. You can reach us at: East Wellington Family Health Team 6 Thompson Cr., Unit 1 Erin, ON N0B 1T0 519-833-7576 PHONE 519-833-0343 or contact us here. If, after contacting us, you feel that your concerns have not been addressed to your satisfaction, we will provide information on other complaint procedures that may be available to you.


Any changes to our Privacy Policy shall be acknowledged in this Privacy Policy in a timely manner.

Email Consent

Here are some of the things that you can email us about

                                    ... and scroll down for the Consent Form to sign up today!

If you send us an email and don’t hear back within 2 business days then please call the office.

Here are some things we can email you about


Email Do’s and Don’ts


To view the Patient Email Communication Agreement, Email Consent  

Please note that email should not be used for medical emergencies or other time-sensitive matters.

Consent for Email Communication

To consent to communicate with the EWFHT via email, please click on the link below to view the full terms and conditions of email consent and complete the agreement form.    Please be aware of the guidelines and Do’s and Don’ts above with regard to what is and what is not appropriate to include in an email: protecting your privacy and confidentiality is a top priority. 

Consent for Patients Under Age 14

A parent/guardian may provide pediatric email consent on behalf of a child under 14 by confirming they have read and agree to the terms, and agree that communication with EWFHT via email is for the purpose of clinical care of the named child. The parent/guardian must provide their name, telephone number, relationship to the child, and the email address to be used.  The parent/guardian does not need to be a patient of EWFHT.  

Prior to the expiration of a pediatric email consent, the EWFHT will contact the parent/guardian and the patient with information on options for patients 14 and over.  If consent is not received from the patient to continue email communication with the original parent/guardian email, that email address will be removed.

IMPORTANT:  In all email communications, please provide the FULL NAME and DATE OF BIRTH of the patient you are writing about.  This is particularly important for spouses and families sharing the same email address.

Inquiries regarding EWFHT’s privacy policies and procedures as they affect any email communications should be directed here


Accessible Customer Service Plan

Providing Goods and Services to People with Disabilities

The East Wellington Family Health Team (EWFHT) is committed to excellence in serving all customers including people with disabilities.

Assistive devices

We will ensure that our staff are trained and familiar with various assistive devices we have on site or that we provide that may be used by customers with disabilities while accessing our goods or services.


We will communicate with people with disabilities in ways that take into account their disability.

Service animals

We welcome people with disabilities and their service animals. Service animals are allowed on the parts of our premises that are open to the public.

Support persons

A person with a disability who is accompanied by a support person will be allowed to have that person accompany them on our premises.

Notice of temporary disruption

In the event of a planned or unexpected disruption to services or facilities for customers with disabilities at either the Erin or Rockwood medical clinics, the EWFHT will notify customers promptly. This clearly posted notice will include information about the reason for the disruption, its anticipated length of time, and a description of alternative facilities or services, if available.

The notice will be placed on the doors of the clinic, on our clinics’ phone messages, and if the internet is not down, on our EWFHT website.


The EWFHT will provide training to employees, volunteers and others who deal with the public or other third parties on our behalf. Training will also be provided to people involved in the development of policies, plans, practices, and procedures related to the provision of our goods and services.

This training will be provided to staff after they are hired.  As well, all staff will receive training.

Training will include:

Staff will also be trained when changes are made to your accessible customer service plan.

Feedback process

Those who wish to provide feedback on the way the EWFHT provides goods and services to people with disabilities can provide feedback either:

All feedback, including complaints, ideally will be provided in writing either via letter or contact us here directing it to the Management Team of the EWFHT.

Those who provide feedback can expect their feedback to be acknowledged in writing within 7-14 business days of receipt of the feedback by the EWFHT.

Those contacting us can expect their feedback to be investigated by the EWFHT Management Team and findings will be communicated back to you within four (4) weeks, unless otherwise notified, i.e.: timelines may be impacted by staff vacations, statutory holidays, etc.

We aim to respond to all feedback within the timelines above; however, if a complaint is complex it may occasionally be necessary to extend the timelines indicated in this policy.  If this is the case, we will keep the complainant informed of progress with the investigation, the reasons for the delay, and inform them of the new deadline.

Notice of availability

The EWFHT will notify the public that our policies are available upon request by posting them on our website and posting a notice in the waiting room of our clinics.

Modifications to this or other policies

Any policy of EWFHT that does not respect and promote the dignity and independence of people with disabilities will be modified or removed.