Hamilton Clinical Chart/notes For Denture/partial Pre-Determination(S) Repairs, Additions And Relines (Page 3 of 4) in pdf

Hamilton Clinical Chart/notes For Denture/partial Pre-Determination(S) Repairs, Additions And Relines Page 3

Appendix A

Patient Name: _______________________________

The oral health of the client must be in good condition in order to insert any prosthetic

appliance or it is destined to failure.

Section D: Service Provider

In completing this form you are confirming that all the statements in this clinical chart/note are true to

the best of my knowledge and belief and no information required to be given has been concealed or

omitted. The Criminal Code of Canada subsection 380 (1) states that everyone who by deceit,

falsehood or other fraudulent means defrauds the public of any property, money or valuable security, is

guilty of an offence.

Name of Service Provider:

Address

Street

City

Postal Code

Date

Day

Month

Year

Phone #

Signature of Service Provider:

NOTE: Ensure estimate is enclosed with this form.

Section E: Patient Authorization

I,___________________________________________, authorize the City of Hamilton Public Health

(Print your name)

Dental and Denture Program to disclose my personal health information (contained on this

form) to the City of Hamilton’s Discretionary Denture Program, 2255 Barton Street, Hamilton ON I

understand the purpose for disclosing my personal health information to the Program noted

above is to determine my eligibility for the Discretionary Denture Program. I understand that I can

refuse to sign this consent form. I further understand that if I do not consent to disclosure of this

information, no eligibility determination will be made.

Date:

dd/mm/yy

Health Card #:

Address:

Phone #:

Patient Signature:

Personal information on this form is collected under the authority of Municipal Freedom of Information and

Protection of Privacy Act (MFIPPA) and Personal Health Information Protection Act, 2004 (PHIPA) and will be

used for the purpose of determining eligibility and provisions of funding for the City of Hamilton’s Discretionary

Denture Program. For more information contact the Special Supports Program Supervisor at 2255 Barton Street

East, Hamilton, 905.546.2424 x 2590.

Created Date: June 2013

Revision Date: October 2013

Hamilton Clinical Chart/notes For Denture/partial Pre-Determination(S) Repairs, Additions And Relines Page 3

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