Consent to Disclose Personal Health Information toVeterans Affairs Canada 1of 1 In order to arrange direct billing with Veterans Affairs Canada (VAC), Hydropothecary is required to provide VAC with personal health information, but your permission is required to do so. You can give this consent by completing and signing this form. This consent will stay in effect until revoked by you or until this application process has been completed. If you wish to revoke your consent, you may do so by contacting Hydropothecary at the address noted below or by calling 1-844-406-1852. The following form of consent to disclose personal health information to VAC was developed by Hydropothecary based on the Personal Health Information Protection Act, 2004 (PHIPA).

PRINT FULL NAME I, authorize The Hydropothecary Corporation to disclose to Veterans Affairs Canada:

Please select one of the following options Check option 1 if you are completing this form for yourself. Check option 2 if you are a substitute decision-maker* for the person obtaining medical marijuana. 1) My personal health information consisting of: the daily quantity of dried marijuana to be used, the specific condition for which the dried marijuana is being used, and any additional information required to validate my eligibility for coverage. SURNAME, GIVEN NAME 2) The personal health information of consisting of: the daily quantity of dried marijuana to be used, the specific condition for which the dried marijuana is being used, and any additional information required to validate the applicant’s eligibility for coverage.

If you selected option 2 above, please read and check the following box as well. I represent and warrant that I meet all of the requirements to be *A substitute decision-maker is a person authorized to consent, on behalf of an individual, to disclose personal health information about the individual under PHIPA or the applicable health information legislation in the jurisdiction in which the applicant resides. The substitute decision-maker is referred to as a ‘Caregiver’ on all other Hydropothecary Forms.

’s substitute decision-maker* under the

SURNAME, GIVEN NAME

applicable legislation.

Your Information I understand the purpose for disclosing this personal information to Veterans Affairs Canada. I understand that I can refuse to sign this consent form.

First Name: Address:

Last Name: STREET

CITY

Telephone no.:

Signature:

1-844-406-1852

120 Chemin de la Rive, Gatineau, QC, J8M 1V2

PROVINCE

POSTAL CODE

E-mail:

Date:

hydropothecary.com

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