Please fill out consent form, then print and sign
APPENDIX "F"- DECLARATION AND CONSENT FORMS
Attached to and forming part of the Agreement among the Ministry, the Physician
Organization, the Hospital, the University and the OMA effective as of the 1st day of April,
2007.
Declaration and Consent Form for Natural Persons as
Participating Physicians or New Participating Physicians
To:
Ministry of Health and Long-Term Care (the "Ministry")
And To:
Hamilton Physicians Association (the "Physician Organization")
And To:
Hamilton Health Sciences Corporation and St. Joseph's Healthcare Hamilton
(the "Hospital")
And To:
McMaster University (the "University")
And To:
Ontario Medical Association (the "OMA")
1.
For the purposes of this Declaration and Consent:
(a)
defined terms that are stated in the singular shall be understood to include the
corresponding plural form and vice versa; and
(b)
capitalized terms used, but not defined, in this Declaration and Consent shall
have the same meanings ascribed to them in the Agreement;
2.
I have read and understand the Agreement.
3.
I would like to be a Participating Physician or a New Participating Physician under the
agreement entered into between the Physician Organization, the Hospital, the
University (collectively referred to as the "Governance Organization"), the Ministry and
the OMA, effective the 1st day of April, 2007 (the "Agreement").
4.
I authorize Dr.
to sign the Agreement on my behalf.
5.
In consideration of the remuneration I will receive from the Governance Organization
as a Participating Physician or New Participating Physician:
and Dr.
(a)
I agree to be bound by the terms and conditions contained in the Agreement and
any amendments to those terms and conditions;
(b)
I assert that I am, and shall continue to be for as long as I am a Participating
Physician or New Participating Physician, a member of the College and hold a
current certificate of registration;
(c)
I assert that I have, and shall maintain for the period during which I provide
Clinical Services, malpractice protection through a commercial insurance
program or through my membership in the CMPA;
(d)
I agree to provide all Services in accordance with the law, contemporary
standards, professional culture and the requirements of the profession;
(e)
I agree to provide the following information on every OHIP claim I submit for
Clinical Services:
(f)
(i)
the AHSC AFP group identifier, meaning the alpha numeric identifier
assigned by the Ministry to signify that a Clinical Service is affiliated
with a group of Participating Physicians and/or New Participating
Physicians providing Clinical Services at an AHSC;
(ii)
the MNI code, meaning the 4 digit code assigned by the Ministry to
identify the location where I provided the Clinical Services; and
(iii)
my OHIP billing number;
I authorize the Ministry to disclose to the Governance Organization and the OMA
the following data in Ministry records relating to any claims I make to OHIP while
I am a Participating Physician or New Participating Physician:
(i)
my name;
(ii)
the fee code for Clinical Services;
(iii)
the date on which I provided the Clinical Services;
(iv)
the amount OHIP paid me for the Clinical Services;
(v)
the AHSC AFP group identifier, meaning the alpha numeric identifier
assigned by the Ministry to signify that a Clinical Service is affiliated
with a group of Participating Physicians and/or New Participating
Physicians providing Clinical Services at an AHSC;
(vi)
the MNI code, meaning the 4 digit code assigned by the Ministry to
identify the location where I provided the Clinical Services;
(vii)
my OHIP billing number; and
(viii)
the number of Clinical Services I provided;
(g)
I agree that the Governance Organization may deduct from monies owing to me
under the Agreement, the amount of my OMA dues and assessments if I do not
pay them;
(h)
if, at any time, I choose to cease to be a Participating Physician or New
Participating Physician, I shall notify my AFP Practice Plan; and
(i)
I agree that subsections 5(f) and (g) of this Declaration and Consent
shall survive the termination or expiry of the Agreement.
6.
The Declaration and Consent shall enure to the benefit of, and be binding upon, the
successors and assigns of the parties hereto.
Date:
Name of Physician:
Signature of Physician:
Name of Witness:
Signature of Witness:
OHIP Number (billing number):
College Registration Number:
AHSC AFP Specialty: