By submitting this Screening Tool and/or Enrolment Form, to Terra Health Network (hereinafter called “Terra Health”), 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 Terra Health. The program provides reimbursement services, medication delivery, compliance and adherence support and is administered by a third party service provider chosen by Terra Health (“Service Provider”).
I hereby authorize Terra Health 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 Terra Health related to my policy. I also authorize my physician or other healthcare professional to disclose to Terra Heath 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 Terra Health 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 Terra Health 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 Terra Health and may be (i) disclosed to the Parties and (ii) shared with and used by Terra Health, its Service Provider, any licensed producers with whom Terra Health works and other third party providers, as necessary in order to provide the Program services. I hereby authorize Terra Health 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:
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 Terra Health at the above-referenced Address for Service within fifteen (15) days of such change.
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