CONSENT INFORMATION: PLEASE READ
I understand that First Nations Health Consortium Ltd. (“FNHC”) operates, provides and otherwise facilitates the provision of enhanced service coordination for First Nations and Inuit families and their dependents throughout Alberta including, but not limited to health, social, education and other services.
These services also include Transitioning to Adulthood, application(s) for registration on the Indian Register and for the Secure Certificate of Indian Status and document processing related to the services provided herein.
The services provided to minors hereunder are pursuant to Jordan’s Principle which ensures that First Nations’ children have equal and fair access to services ordinarily available to other Canadian children and to shield them from government disputes. FNHC does not provide the actual health, social, education or other services nor is it an agent for any such service provider or the Applicant.
I, the Applicant, hereby confirm that:
(A) I have read and understand this Consent Form, and hereby consent and agree to the contents thereof on my behalf and on behalf of my dependent(s) noted above.
(B) I authorize and give my consent to FNHC, its agents and duly authorized employees, the claims administrator(s) or anyone who acts for or on its behalf including but not limited to health care, social, education and other service professionals or providers and First Nations and Inuit Health Branch, Department of Indigenous Services Canada/Government of Canada – Jordan’s Principle Focal Points to collect, use, disclose, exchange and share my personal information including health information, individually identifying information, and health related and claims processing information (“personal information”) and that of any dependent(s) noted above with any party for purposes related to confirm eligibility, facilitate access to services, assist applications and appeals, and for purposes related to the administration, delivery and management of services provided hereunder and for other purposes as described herein.
(C) FNHC is authorized to use the personal information collected for statistical purposes, quality assurance, planning and program development. For such purposes, said personal information shall be used only in generic and statistical manner, without any reference to any material that may identify the recipient of benefits or result in personal information specifically about the recipient of benefits included in the dissemination or gathering of such information.
(D) This consent is valid for as long as it is needed for purposes of FNHC and any services provided to the Applicant or any dependent(s) thereunder. The Applicant may withdraw or amend consent at any time on giving written notice to First Nations Health Consortium and I understand that revocation will not affect any action taken by FNHC prior to receipt of such revocation.
(E) I am the Applicant or parent or guardian of the dependent(s) noted above, such dependent(s) being under the age of 18 years and/or dependent adult, and I am duly authorized to provide this consent in my personal capacity and on behalf of each of my dependent(s) noted above.
