Consent Service Agreement, Community Program

• I acknowledge that I have been informed of my rights and responsibilities as a Bethell Hospice client. A copy of the Bethell Hospice Patient Bill of Rights has been given to me, and I am aware that these can also be found on the Bethell Hospice website.

• I understand that Bethell Hospice will protect the privacy of my personal health information in accordance with the Personal Health Information Protection Act, 2004.
• I understand that Bethell Hospice may receive and share my personal health information with other healthcare partners within my circle of care, unless I notify Bethell Hospice in writing that I do not want Bethell Hospice to do so.
• I understand that as part of the intake process into the Bethell Hospice Community program, I will be asked whether I consent to the sharing of my contact information with the Bethell Hospice Foundation. I understand that I have the choice to consent or to decline to the sharing of my information with Bethell Hospice Foundation.
• I understand that there are cases where Bethell Hospice may collect, use or share my health information without my permission, as permitted or required by law, including, but not limited to: sharing between Bethell Hospice personnel for purposes related to service delivery and use of information for risk management or quality improvement initiatives. I understand that safety supersedes confidentiality when persons are at risk and Bethell Hospice personnel may disclose information without my consent to keep me or someone else safe.
• If I would likely more information about Bethell Hospice’s privacy practices, its Privacy Statement is available online at: Bethell Hospice Privacy Statement

• I am aware that my care needs will be reviewed, and my care plan updated as required.
• If my condition improves or stabilizes to the point where I no longer require and/or am eligible for Bethell Hospice Community Program, I understand Bethell Hospice can withdraw services.
• I understand that not all Bethell Hospice staff and volunteers are medical personnel and are unable to determine the nature of a medical emergency. I understand that if a Hospice staff or volunteer is alone with a client who experiences a medical emergency – 911 will be called.
• Bethell Hospice endeavors to provide a safe and respectful environment. Deliberate aggressive and/or threatening behaviour (physical, emotional, psychological, sexual) is not tolerated towards staff and volunteers of Bethell Hospice, nor other clients, families, and friends. I understand that if this occurs, a warning will be issued, police may be called and/or service may be terminated.
• I understand that due to the high number of referrals for the programs and services offered, there is a potential for service provision to be delayed. If a program is not running or is at capacity at the time, and I am referred to it/or request it, my name will be placed on a ‘wait-list’ until it becomes available.

• I understand that volunteers are part of the Bethell Hospice team who are trained to work in specific roles and contribute to my experience while enrolled in service with Bethell Hospice.

• I understand and accept the conditions noted above. I agree to release and indemnify Bethell Hospice or any directors, officers, volunteers, agents and employees from all claims and liability for any of the following:

1. Personal injury, illness, incapacity, or death that occurs, or
2. The loss of money, valuables and personal effects unless held in safe keeping by the Hospice.
3. Loss of property or damage (unless intentionally committed).
4. Any care provided to me other than by the employees and agents of the Hospice.

• I agree to release Bethell Hospice along with its directors, officers, volunteers, agents, 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 services by Bethell Hospice except if claims arise from intentional or deliberately harmful or criminal actions.

• I understand that the services of the hospice residence and community programs are provided at no cost thanks to the generosity of donors, community partners and government funding. Financial donations, in-memoriam donations and bequests are gratefully accepted. To discuss donation opportunities, please contact the Foundation office at [email protected].

• Bethell Hospice is committed to providing an accessible experience in which all individuals have equal access to our services and facilities as required by the Accessibility for Ontarians with Disabilities Act, 2005