Clinic Forms

Click on the links below to print off a copy of our Intake Form and Consent to Disclose form.

Please note that the client/patient must bring the intake forms to their initial visit at Mamaway Wiidokdaadwin Primary Care Clinic.

Phone to book your appointment at either location.

Mamaway Intake Form

Consent to Disclose PHI June 2019

Referral Consent Form

Feel free to contact our clinics for more information.

Personal Health Information and Privacy

Ontario has a law that protects your personal health information, including information about you at this facility.

We are required to keep your personal health information safe and secure. You have the right to know how we may use and give it out and how you can get access to it.

Your personal health information must be kept private and secure. You or a person who can legally make decisions for you about your personal health information can use and see it.

Your personal health information is shared among your doctors, nurses, care givers, and all other team members who provide care and assistance to you.

We may collect, use and give out your personal health information to others, as reasonably necessary to:

  • provide you with health care and assistance, both within and outside our care facility;
  • communicate or consult about your health care with your doctor(s) and other health care providers;
  • do health system planning and research; and
  • report as required or permitted by law.

There are certain other circumstances where we may be required to give out some of your personal health information.

You or a person who can make decisions for you about your personal health information have the right:

  • to see and get a copy of your personal health information;
  • to ask us to make corrections to inaccurate or incomplete personal health information;
  • to ask us not to give out your personal health information to other health care providers
  • we will not give out this information unless permitted or required by law to do so; and
  • to be told if your personal health information is stolen, lost or improperly accessed.

There are certain exceptions to these rights; please contact our Privacy Officer for details.

When you give us permission to use or give out your information, you may change your mind at any time.

However, sometimes the law permits or requires us to share your information without your permission. To make your choices, please speak to our Privacy Officer.

  • We may be asked to give your personal health information to a research project.
  • We will get your permission before we use or give out your personal health information for these projects.
  • There are also other types of research projects which do not require your consent; these must have safeguards in place to protect your privacy.
  • We may use your personal health information without your consent for our own education, planning and management.
  • We may also give out your personal health information to certain listed organizations for use in the planning and management of the health care system.
Information and Privacy Commissioner of Ontario
2 Bloor Street East, Suite 1400, Toronto, Ontario, M4W 1A8
Toll Free: 1-800-387-0073; www.ipc.on.ca
Barrie Area Native Advisory Circle
125 Bell Farm Road, Suite 200
Barrie ON L4M 6L2
Privacy Officer
249-288-2192
privacy@banac.on.ca