A Program of the North Simcoe Muskoka Hospice Palliative Care Network
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Section A: Program Overview (required)
Consent for Services:
I consent to receive services from Hospice Orillia. I agree to collaborate with the staff from Hospice Orillia to determine what type of support and which services I will receive. I understand that this information will be used to create my care plan, which will be reviewed periodically. I understand that I have the right to withdraw my consent for services at any time.
Eligibility, Exclusion, and Transition Criteria
I understand that in order to receive services from Hospice Orillia, I must meet the eligibility criteria listed below:
• Reside in Hospice Orillia’s service area
• Be 16 years of age or older
• Experiencing a life-limiting illness, or caregiving for someone experiencing a life-limiting illness
I understand that if I no longer meet the eligibility requirements, or if my needs extend beyond the capacity of Hospice Orillia, the staff will work with me in order to facilitate the transition of care.
I understand that Hospice Orillia has the right to withdraw services if a risk is identified which would place Hospice Orillia staff and volunteers in an unsafe environment, or if I do not make contact with the Community Social Worker for a continuous period of three months.
Confidentiality & Release of Information
I understand that all personal information shared with Hospice Orillia staff and volunteers is confidential, as per the Personal Health Information Protection Act of 2004. I understand that information sharing between the service providers in my circle of care, and shall be for the sole purpose of providing quality service to meet my care needs. I understand that if my safety or another person’s safety is at risk, Hospice Orillia has the duty to report. I understand that I have the right to withdraw this consent at any time.
I give consent to Hospice Orillia to:
Share my personal health information in the Hospice Orillia Community Program, and with Hospice Orillia staff as needed to complete my goals of care.
Receive and share all personal health information with all healthcare providers within my circle of care.
Share my personal health information at Community Rounds as needed to ensure continuity of care.
Complete quarterly Quality of Care surveys with myself or (enter the name of whom we are permitted to conduct Quality of Care surveys with):
who is my (enter relationship)
Fees for Service
I understand that Hospice Orillia does not charge any fees for their services. I understand that this is made possible through funding from the North Simcoe Muskoka Home and Community Care Support Services (previously known as North Simcoe Muskoka Local Health Integration Network (LHIN)) and generous donations from the community (including memorial donations).
Rights and Responsibilities
I acknowledge that I have been informed of my rights and responsibilities as a client of Hospice Orillia. A copy of the Rights and Responsibilities document has been provided to me, and I have been advised of the complaint procedure.
I understand that Hospice Orillia volunteers have received 30 hours of training to provide compassionate, emotional, social, and spiritual support, and have undergone a police records check prior to becoming a Hospice volunteer. All Hospice Orillia volunteers are supervised by professional staff members.
I have been informed of the waitlist procedures at Hospice Orillia. All Hospice Orillia programs operate on a waitlist. An individual’s spot on the wait list is determined by need and suitability of volunteer. I understand that Hospice Orillia utilizes a waitlist for these services to allow for equal access to services for all.
I acknowledge that I have been informed of the scope of the programs and services offered by Hospice Orillia, and have been provided a copy of the Program Scope document.
Section B: Complementary Therapies (skip to Section C if not applicable)
I understand that Hospice Orillia complementary therapy services are provided by trained therapists who are volunteering their time and talents. All volunteer therapists have completed all Hospice Orillia training and security requirements.
I understand that the complementary therapies offered by Hospice Orillia volunteers are aimed at reducing stress and promoting relaxation. I am aware that the therapists do not claim to cure or to diagnose any medical condition, nor interfere with treatment of a licensed medical professional. I understand that complementary therapies do not replace other medical care. I understand that if at any point during a session I feel uncomfortable, I understand that I have the right to ask questions, or to terminate the session.
Section C: Emergency Response (skip to Section D if not applicable)
I understand that Hospice Orillia staff and volunteers are not medical personnel, and are unable to determine the nature of medical emergencies or provide treatment. I understand that if a Hospice Orillia staff member or volunteer is alone with me, and I experience a medical emergency, 911 will be called.
Do you have a written DNR order in place?
Section D: Virtual Services (skip to Section E if not applicable)
I give my consent for Hospice Orillia staff/volunteers to use a public third-party cross-platform messaging or video communication application or program (i.e. Zoom, OTN or other) in order to receive virtual service.I understand that although Hospice Orillia has taken appropriate precautions to protect personal health information and respect confidentiality, Hospice Orillia is not responsible for the unintentional sharing or distribution of any personal health information that may be expressed or communicated while providing supports using any public forms of communication.I understand that I am solely responsible for safeguarding my user identification and password(s). I understand that I will not allow another person to use my user identification and/or passwords to utilize services.
Virtual Meeting Etiquette
I understand that I must take part in a video call in a suitable environment and be appropriately dressed. I understand that I am responsible for using technology in a secure and private location so that others cannot hear my conversations.I understand that when using virtual settings, technological errors may occur. In the event I am disconnected from a meeting, I will make every effort to rejoin on my own. I understand that Hospice Orillia staff/volunteers are not able to troubleshoot technological errors when a meeting has begun.
Section E: Waiver & Acknowledgement (required)
I agree to release and hold harmless Hospice Orillia along with its directors, volunteers and employees of all actions, claims or demands of any nature or kind arising out of or in any way connected with the provision of service by Hospice Orillia except if claims arise from intentional or deliberately harmful or criminal actions.
I have read the provisions of this agreement and understand their meaning.
This service agreement is valid for one year, and will expire one year from the date of submission.
Form completed by:
ClientPower of AttorneySubstitute Decision MakerGuardian