Version 1.1 Last Revised: June 20 2017
By submitting this Screening Tool and/or Enrolment Form, to Solace Health Network (hereinafter called ”SHN”), I hereby acknowledge that in doing so, I will be enrolled in the Medical Cannabis Patient Enrolment Initiative Program (the “Program”) which will be used to consider me for treatment with Marijuana (or Cannabis) for Medical Purposes, as that term is defined in the Access to Cannabis for Medical Purposes Regulations (the ”Treatment”). The program is a patient assistance program for Canadian patients who have been, or are looking to be prescribed medical cannabis, and is provided by SHN. The program provides reimbursement services, medication delivery, compliance and adherence support and is administered by a third party service provider chosen by SHN (“Service Provider”).
I hereby authorize SHN to investigate and determine my insurance benefit potential on my behalf and direct third party plans under which I am eligible for drug benefits to release coverage information to SHN related to my policy. I also authorize my physician or other healthcare professional to disclose to SHN such information related to my relevant medical condition as may be required by my insurance provider(s) and/or pharmacy in order to process my insurance claim(s) and authorize SHN to share this information with my insurer(s) and/or pharmacy as is required to process such claim(s) and to assist with prescription services. I understand that SHN may also request additional supporting documentation from me, including financial information, for purposes of verifying insurance coverage, to provide prescription services or to otherwise arrange for financial coverage for my use of the prescribed medication(s) and I consent to being contacted by mail or telephone at the address and telephone numbers included in the Screening and Enrolment Form. I understand that Personal Information will be used by SHN and may be (i) disclosed to the Parties and (ii) shared with and used by SHN, its Service Provider, any licensed producers with whom SHN works and other third party providers, as necessary in order to provide the Program services. I hereby authorize SHN to contact me in order to provide me with educational and support services associated with my condition, my Medical Cannabis therapy and other information required for the administration of the Program and my Treatment.
I acknowledge and confirm that by submitting the Screening Tool and/or Enrolment Form that:
- This form is not and will not be used as a diagnostic tool by SHN
- I will obtain and receive my own medical advice and/or diagnostic instructions from my health care provider
- SHN is not making any recommendation of therapies to be provided to me
- If a Health Care Provider submitted this Enrolment Form, they are responsible for the accuracy of all of the information contained therein and any care requested for their patient
- I will be contacted by SHN’s Service Provider(s) including their educators, medical professionals, nurses and other associated service providers required in the delivery of the Treatment requested here-under.
- When communicating with me, representatives of SHN and its Services providers, from time-to-time ask me to identify myself by asking me questions for purposes of such authentication, including my full name, date of birth, full address (including my postal code) and my phone number.
I further acknowledge and confirm that should any of my personal information as is contained in the Screening Tool and Enrolment Form change, that I will provide written notice of such change to SHN at the above-referenced Address for Service within fifteen (15) days of such change.
OWNERSHIP AND RESTRICTIONS OF USE
This website and our other sites (Collectively “Sites”) are owned and operated by SHN Any and all content, data, graphics, photographs, images, audio, video, software, systems, processes, trademarks, service marks, trade names and other information including, without limitation, the “look and feel” of the Site (collectively, the “Content”) contained on our Sites are proprietary to our organization and the Content is protected by Canadian copyright and trademark laws.
Except as set forth herein, you may not modify, copy, reproduce, publish, post, transmit, distribute, display, perform, create derivative works from, transfer or sell any Content without the express prior written consent of our organization. You may download, print and reproduce the Content for your own non-commercial, informational purposes provided you agree to maintain any and all copyright or other proprietary notices contained in such Content, and to cite the URL Source of such Content. Reproduction of multiple copies of the Content, in whole or in part, for resale or distribution is strictly prohibited except with the prior written permission of our organization. To obtain written consent for such reproduction, please contact us at firstname.lastname@example.org.
Access to certain areas of our Sites are restricted. If we provide you with credentials (for example a user ID and password) to enable you to access restricted areas of our Sites or Content or services, you must ensure that that the credentials are kept confidential.
If you have any reason to believe that your credentials are not confidential, or have not been compromised, you must inform us immediately.
DISCLAIMER OF WARRANTIES
The materials on our Sites are provided “as is”. We make no warranties, expressed or implied, and hereby disclaims and negates all other warranties, including without limitation, implied warranties or conditions of merchantability, fitness for a particular purpose, or non-infringement of intellectual property or other violation of rights. Further, our organization does not warrant or make any representations concerning the accuracy, likely results, or reliability of the use of the materials on its Sites or otherwise relating to such materials or on any external websites.
You must ensure that any software downloaded from this Site or from the Internet is suitable for use on your computer and that it is free from viruses. It is solely your responsibility to virus check any software loaded from our Sites and to check that it is compatible with your computer. We can accept no responsibility for any damage caused to you or to any third parties by any material, which you download from our Sites.
VIRUSES, DAMAGES & AVAILABILITY
We make no warranty or claim that functions available on our Sites will be uninterrupted or error free, that defects will be corrected, or that the server that makes it available, nor the content itself is and/or will be free of viruses, bugs, or other malicious code. You acknowledge that it is your responsibility to implement sufficient procedures and virus checks (including anti-virus and other security checks) to satisfy your particular requirements for the accuracy of data input and output, and for the security of yourself and the device used by you to view any content.