Natural Care Group

Consent to Disclose Personal Health Information

Pursuant to Health Information Protection Act, 2005, (HIPA) | Version 1.2 Oct 2013

In order to provide our services to you, Natural Care Group Inc. (“Natural Care”) requires your consent to disclose information to, and to receive information from the following: Natural Care medical prescribers, your physician, your chosen licensed medical cannabis producer(s), and if applicable, your retirement or long-term care home and/or pharmaceutical provider.

I acknowledge, agree and/or grant permission:

    1. To Natural Care to access my medical document, which is required by a licensed producer and contains my contact information and some details about my medical cannabis dose.
    2. To the licensed producer to share my application and medical documents with Natural Care for tracking and informational purposes.
    3. To Natural Care and my retirement home, group home, long term care home, home care provider, physician, caregivers and pharmacy to share my medical history, medication plan and medical document as needed to facilitate my care.

I also acknowledge, agree and/or grant permission:

1. To Natural Care to send occasional electronic messages containing useful information about medical cannabis, as well as Natural Care’s services and events. I understand that I can unsubscribe from these emails at any time.