Patient Family Rostering | Appletree Medical Group

PATIENT INFORMATION

Name*

First Middle Last

OHIP HEALTH CARD NUMBER + VERSION CODE*

Date of Birth*

Sex*

Male
Female

Mailing Address*

Street Address Address Line 2 City Province Postal Code

Which Appletree Group do you want to book into?*

The Ottawa Group
The Toronto Group

Is your mailing address the same as your residence address?*

Yes
No

Residence Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Phone*

CHILD(REN) UNDER 16 AND/OR DEPENDANT ADULT(S)

Are you enrolling yourself only or at least one child(ren) or dependant(s)?*

Myself only.
Child(ren) or Dependant(s)

Name - Child or Dependant #1*

First Middle Last

OHIP HEALTH CARD NUMBER + VERIFICATION CODE*

Date of Birth*

Sex*

Male
Female

Child and/or dependant #1's residence and mailing address are the same as mine:*

Yes
No

Residence Address*

Street Address Address Line 2 City Province Postal Code

I am this person's:*

Parent
Legual Guardian
Attorney for Personal Care

Add a second child or dependant?*

Yes
No

Name - Child or Dependant #2*

First Middle Last

OHIP HEALTH CARD NUMBER + VERIFICATION CODE*

Date of Birth*

Sex*

Male
Female

Child and/or dependant #2's residence and mailing address are the same as mine:*

Yes
No

Residence Address*

Street Address Address Line 2 City Province Postal Code

Residence Address*

Street Address Address Line 2 City Province Postal Code

I am this person's:*

Parent
Legual Guardian
Attorney for Personal Care

Add a third child or dependant?*

Yes
No

Name - Child or Dependant #3*

First Middle Last

OHIP HEALTH CARD NUMBER + VERIFICATION CODE*

Date of Birth*

Sex*

Male
Female

Child and/or dependant #3's residence and mailing address are the same as mine:*

Yes
No

Residence Address*

Street Address Address Line 2 City Province Postal Code

I am this person's:*

Parent
Legual Guardian
Attorney for Personal Care

SECTION 3 | Signature

I am signing on behalf of:*

Myself
Child(ren)
Dependant adult(s)

Please type your signature (Enter first and last name)*

First Last

Date*

SECTION 4 | Patient Consent

Patient Consent*

I have read and agree to the Patient Commitment, the Consent to Release Personal Health Information and the Cancellation Conditions below. I acknowledge that this Enrolment is not intended to be a legally binding contract and is not intended to give rise to any new legal obligations between my family doctor and me.

PATIENT COMMITMENT

I agree to contact my family doctor, (or if applicable the group to which my family doctor belongs or the designated Telephone Health Advisory Service if available to me), when I, or my enrolled child(ren) or dependent adult(s), need primary care medical advice or treatment. I promise to do this unless there is an emergency or I am travelling away from home.

I agree that if I or the person(s) I have signed for move, I will contact my family doctor’s office or the ministry (see box below) with a new address and telephone number.

I understand that I can end my enrolment with this family doctor and enrol with another family doctor after six weeks have passed from the date that I complete and sign this form (immediately if I have moved). However, I agree not to change the doctor with whom I am enrolled more than twice a year.

I understand that by enrolling a child under 16 or a dependent adult, my signature on the front of this form means that I agree to these terms and conditions on behalf of that person. When an enrolled child reaches 16 years of age, the ministry will contact him or her to confirm enrolment/consent with the family doctor.
CONSENT TO RELEASE PERSONAL HEALTH INFORMATION

I understand that my family doctor will be able to offer better medical care if I permit my family doctor and the ministry to share appropriate and relevant information relating to my health.

I agree to allow my family doctor, other family doctors in the Patient Enrolment Model (if applicable) and the ministry to exchange the information in this form related to my enrolment.
I agree that my family doctor and the ministry can exchange information about my name, address and telephone number. I agree to allow the ministry to release the following specific information to my family doctor:

- dates of immunizations (flu shots, etc.)
- dates of preventive care screening services (pap tests, mammograms, etc.)
- dates of service, fees paid and fee codes of primary health care services provided to me by a family doctor outside my family doctor’s Patient Enrolment Model (if applicable).

If the Telephone Health Advisory Service is available to me, I agree to allow my family doctor and the ministry to exchange only the following information with the designated Telephone Health Advisory Service: my name, health number and version code, address, date of birth, gender.

I understand that this consent to release personal health information ends when:

- My enrolment with my family doctor ends or
- I cancel my consent by writing or telephoning the Ministry of Health and Long-Term Care (see box below).
- The ministry will inform my family doctor when the consent is no longer valid. However, I understand that the information already released to my family doctor will remain in my medical file.
CANCELLATION CONDITIONS

Enrolment with my family doctor and my consent to release personal health information will end when:

- I cancel my enrolment by writing my family doctor or by writing or telephoning the ministry (see box below);
- I no longer qualify for health care services under the Health Insurance Act (Ontario);
- the Patient Enrolment Model to which my doctor belongs no longer exists;
- my family doctor chooses to discontinue acting as my family doctor in accordance with the College of Physicians and Surgeons of Ontario guidelines;
- I enrol with another family doctor; or the ministry grants me an extended absence.

My enrolment with my family doctor and my consent to release personal health information may end when:

- I consistently fail to meet the obligations to which I agreed in the Patient Commitment (above);
- my family doctor leaves this Patient Enrolment Model;
- I become a resident of a long-term care facility;
- I am imprisoned in a provincial or federal correctional institution; or
- I move outside the geographic area where the Patient Enrolment Model to which my family doctor belongs regularly provides services.
CONTACT INFORMATION

Ministry of Health and Long-Term Care
P.O. Box 48, Station Main Kingston ON K7L 929
Call: INFOline: 1 888 218-9929
TTY: 1 800 387-5559

Please answer the following mathematical question: 10+10-5=?*

Please enter a number from 15 to 15.

Reminder that completing this form does not mean that you are rostered to our Family Practice. Once we receive your request, we will mail you the paper enrollment form to sign and complete and will ask that you return it to us to become rostered.

Services

Appletree Family Health Group Request Form

PATIENT INFORMATION

CHILD(REN) UNDER 16 AND/OR DEPENDANT ADULT(S)

SECTION 3 | Signature

SECTION 4 | Patient Consent

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