COLLECTION OF PERSONAL AND PERSONAL HEALTH INFORMATION

This information is being collected under the authority of the Health Protection and Promotion Act, R.S.O. 1990, c.H.7 for the purposes of the control of infectious diseases and diseases of public health significance, including the provision of immunization services; protecting the health of individuals against vaccine preventable diseases; the administration of Ontario’s COVID-19 vaccination program including creating an electronic immunization record; client follow up and the provision of statistical data to the Ministry of Health. Information will be collected, used, and disclosed in accordance with the Personal Health Information Protection Act, 2004, S.O. 2004, c. 3 as well as other purposes authorized and required by law.

This information will be used and disclosed for these purposes, as well as other purposes authorized and required by law. For example,

– it will be disclosed to the Chief Medical Officer of Health and Ontario public health units where the disclosure is necessary for a purpose of the Health Protection and Promotion Act. And
– it may be disclosed, as part of your provincial electronic health record, to health care providers who are providing care to you. The information will be stored in a health record system under the custody and control of the Ministry of Health.

CONSENT TO THE COLLECTION OF INFORMATION

I consent to Medical Associates of Port Perry and the North Durham Family Health Team electronically collecting personal and personal health information for the following purposes:

•To book a COVID-19 vaccination appointment,
•To text or email you to confirm your upcoming appointment and/or changes to your scheduled appointment,
•To keep an electronic record of immunization, and
•To provide health care providers with electronic access to immunization information for the provision of health care.

WITHDRAWING CONSENT

You may withdraw your consent to the collection, use and/or disclosure of your information at any time. Questions about this collection of information should be addressed to the Privacy Officer at 462 Paxton Street, Port Perry, ON, L9L 1L9. By selecting the “I Accept” button I acknowledge that:I have read, understood and accept how information will be collected, used and disclosed by Medical Associates of Port Perry and the North Durham Family Health Team.

More Information about data collection

The personal health information on this form is being collected for the purpose of providing care to you and creating an immunization record for you, and because it is necessary for the administration of Ontario’s COVID-19 vaccination program. This information will be used and disclosed for these purposes, as well as other purposes authorized and required by law.

For example:

(1) It will be disclosed to the Chief Medical Officer of Health and Ontario public health units where the disclosure is necessary for a purpose of the Health Protection and Promotion Act.

(2) It may be disclosed, as part of your provincial electronic health record, to health care providers who are providing care to you. The information will be stored in a health record system under the custody and control of the Ministry of Health.

Medical Associates of Port Perry/North Durham Family Health Team will also collect, use and disclose your information as an agent of the Ministry of Health. 

You may be contacted by Medical Associates of Port Perry/North Durham Family Health Team, the Durham Region Health Department, or the Ministry of Health for purposes related to the COVID-19 vaccine (for example, to remind you of follow up appointments and to provide you with proof of vaccination).