Purpose and Consent: The information collected on this form is for the purpose of placing you and your immediate family (“you”) on a waitlist for a family physician with the Kincardine Family Health Organization (“KFHO”). Your information will be retained for the sooner of (a) three years since our last contact with you; or (b) upon your request for removal.

The Kincardine Family Health Team (“KFHT”) is the health information custodian that controls your information on behalf of the KFHO, and both the KFHT and KFHO are committed to ensuring your information is protected according to the Ontario Personal Health Information Protection Act. Both the KFHT and KFHO limit the collection, use, retention, and disclosure (collectively, “manages”, “management”, or “managing”) of your information to those uses and disclosures that are reasonably necessary for the purposes outlined.

By submitting your information to us to be added to the waitlist, you consent to the management of your information for the purpose of facilitating this waitlist. If you have any questions regarding how this information is managed, please email our Privacy Officer at privacy@kincardinefht.ca.

Are you Eligible? Only residents of the Municipality of Kincardine and the Township of Huron-Kinloss may join this waitlist. If you reside outside of these areas, KFHT will not be able to add you to our waitlist. Only complete this form once. Duplicate entries will be deleted.

How to Join the Waitlist: If you are eligible, please provide the KFHT the information requested below, and include your preferred method of contact. If you would prefer to add your name to the waitlist in paper form, please visit the KFHT or KFHO to complete or drop off a waitlist form at the reception desk. In the event your information changes, please contact us to keep your submission accurate and up-to-date.

Random Draws determine whether you are contacted to be Rostered to a Physician: When the KFHO has capacity for new patients, the KFHT will conduct a random draw from all eligible individuals signed up on the waitlist. Selected individuals will be contacted by either the KFHT or the KFHO at the phone number or email provided on this form. If the selected individual does not respond to and confirm their acceptance of being placed with a KFHO primary care provider within 5 business days of KFHT or KFHO attempting contact, then the KFHT will conduct a new draw with the formerly selected individual’s information being returned to the waiting list.

To Whom do we Disclose your Information? Smartsheet hosts the information you submit online on our behalf, and Smartsheet will primarily process your Information in the United States. Please see Smartsheet’s list of subprocessors to learn more https://www.smartsheet.com/legal/subprocessors. Additionally, we may anonymize your information by stripping it of your name and contact details, and disclose to the local, provincial, or federal governments or other organizations in the health space the number of individuals on the waitlist.

In the event you do not wish to use Smartsheet to provide us your Information, please email our Privacy Officer at privacy@kincardinefht.ca for alternative methods of signup.

What is our Retention Period: Upon three years of having your information on the waitlist, either the KFHT or KFHO will contact you to verify whether you still wish to remain on the waitlist. If you do not confirm you wish to remain on the waitlist within 30 days, KFHT will remove your information.

Disclaimer: Please note that completion of this form will only place you on a waitlist, and placement on such waitlist does not guarantee that you will be rostered to a physician or nurse practitioner (“primary care provider”). Due to the high demand for primary care providers, KFHO cannot predict the amount of time you may have to wait before you are selected to be matched with a primary care provider. Completion of this form does not create a patient-provider relationship.