Consent to receive Interim Federal Health Program (IFHP) services

 

  1. Consent to Care

I consent to receive:

  • Parenting coaching
  • Mental health support
  • Trauma-informed and counselling-informed services
  • Psychoeducation and counselling-informed support
  • Stress, trauma-informed, and family wellness support

These services are provided by regulated and trained professionals including Registered Nurses, Psychotherapists, and certified educators.

Services are not emergency, medical, psychiatric, or hospital-based care.

I understand:

    • I may withdraw consent at any time
    • I may request my records
  • My information is protected under Canadian privacy law (PHIPA & PIPEDA)

  1. Authorization to Communicate with Health Care Providers

I authorize Parents Coach Network to communicate with my health care providers, including but not limited to physicians, hospitals, and allied health care professionals, for the purpose of supporting my care, continuity of services, and IFHP billing.

  1. Consent to Share Personal & Health Information (PHIPA)

I consent to the collection, use, and disclosure of my personal and personal health information by Parents Coach Network in accordance with Ontario’s Personal Health Information Protection Act (PHIPA) and other applicable privacy laws for the purposes of:

  • providing care
  • coordinating services
  • communicating with my health care providers
  • IFHP billing and administration
  • clinical documentation and record keeping

  1. Consent to Internal Team Sharing

I consent to the sharing of my personal and health information within the Parents Coach Network care team, including Registered Nurses, psychotherapists, educators, administrators, and authorized staff, when necessary to support my care, scheduling, supervision, documentation, and IFHP billing.

  1. Limits of Confidentiality

I understand that my information will not be shared outside of Parents Coach Network without my consent except where required or permitted by law, including situations involving risk of harm, abuse, or court orders.

  1. IFHP Coverage & Service Termination

I authorize Parents Coach Network to:

  • Collect my IFHP number
  • Verify my coverage
  • Submit claims on my behalf
  • Communicate with Medavie Blue Cross or IFHP administrators

  1. Client Responsibility for Changes

IFHP Coverage Requirement
I understand that services at Parents Coach Network (PCN) are provided based on my active eligibility under the Interim Federal Health Program (IFHP).

My services automatically end when my IFHP coverage ends, expires, is suspended, or becomes inactive.

I understand that IFHP coverage can change without notice. I am responsible for informing PCN of any changes that may affect my eligibility.

I agree to notify Parents Coach Network as soon as possible if I anticipate any change to my immigration status, refugee claim, work permit, or IFHP eligibility. I will, therefore, be transferred to services covered by the Ontario Health Insurance Program (OHIP).

If services are provided while my IFHP is inactive or expired, I understand that I may be personally responsible for payment.

  1. Appointment & No-Show Policy

IFHP does not pay for:

  • Missed appointments
  • Late cancellations
  • Sessions ended early

I understand that:

  • 24 hours’ notice is required to cancel
  • Cancellation without 24-hour-notice for 3 times or more may subject to termination of service

  1. Privacy & Confidentiality

My personal and health information will only be used for:

  • Care delivery
  • IFHP billing
  • Required clinical documentation

Information will not be shared without consent except where required by law.

 

Name
Consent to receive Interim Federal Health Program (IFHP) Services I consent to receive: Parenting coaching Mental health support Trauma-informed and counselling-informed services Psychoeducation and counselling-informed support Stress, trauma-informed, and family wellness support These services are provided by regulated and trained professionals including Registered Nurses, Psychotherapists, and certified educators. Services are not emergency, medical, psychiatric, or hospital-based care. I understand: I may withdraw consent at any time I may request my records My information is protected under Canadian privacy law (PHIPA & PIPEDA) Authorization to Communicate with Health Care Providers I authorize Parents Coach Network to communicate with my health care providers, including but not limited to physicians, hospitals, and allied health care professionals, for the purpose of supporting my care, continuity of services, and IFHP billing. Consent to Share Personal & Health Information (PHIPA) I consent to the collection, use, and disclosure of my personal and personal health information by Parents Coach Network in accordance with Ontario’s Personal Health Information Protection Act (PHIPA) and other applicable privacy laws for the purposes of: providing care coordinating services communicating with my health care providers IFHP billing and administration clinical documentation and record keeping Consent to Internal Team Sharing I consent to the sharing of my personal and health information within the Parents Coach Network care team, including Registered Nurses, psychotherapists, educators, administrators, and authorized staff, when necessary to support my care, scheduling, supervision, documentation, and IFHP billing. Limits of Confidentiality I understand that my information will not be shared outside of Parents Coach Network without my consent except where required or permitted by law, including situations involving risk of harm, abuse, or court orders. IFHP Coverage & Service Termination I authorize Parents Coach Network to: Collect my IFHP number Verify my coverage Submit claims on my behalf Communicate with Medavie Blue Cross or IFHP administrators Client Responsibility for Changes IFHP Coverage Requirement I understand that services at Parents Coach Network (PCN) are provided based on my active eligibility under the Interim Federal Health Program (IFHP). My services automatically end when my IFHP coverage ends, expires, is suspended, or becomes inactive. I understand that IFHP coverage can change without notice. I am responsible for informing PCN of any changes that may affect my eligibility. I agree to notify Parents Coach Network as soon as possible if I anticipate any change to my immigration status, refugee claim, work permit, or IFHP eligibility. I will, therefore, be transferred to services covered by the Ontario Health Insurance Program (OHIP). If services are provided while my IFHP is inactive or expired, I understand that I may be personally responsible for payment. Appointment & No-Show Policy IFHP does not pay for: Missed appointments Late cancellations Sessions ended early I understand that: 24 hours’ notice is required to cancel Cancellation without 24-hour-notice for 3 times or more may subject to termination of service Privacy & Confidentiality My personal and health information will only be used for: Care delivery IFHP billing Required clinical documentation Information will not be shared without consent except where required by law.