Consent for collection, use and disclosure of personal information
I understand that it is necessary to provide personal information to Doctors Manitoba so they can determine my eligibility for the CME Rebate Program. I understand that “personal information” includes, but is not limited to, my name, addresses, date/location of birth, gender, other demographic information, bloc of practice, specialty, billing number(s), practice/billing profiles, all contractual terms with, and financial compensation from, the Province of Manitoba (Manitoba Health and any other Department/Agency), University of Manitoba, any Regional Health Authority, Workers Compensation Board, Manitoba Public Insurance and any other employer or contractor, including fee-for-service payments, salary and/or contract payments, sessional payments, administrative and other stipends, on-call payments and other compensation and benefits.
I understand that this authorization will continue in full force until revoked by me in writing. I authorize Doctors Manitoba to access, collect, use and disclose my personal information for the following limited purposes:
- To determine my eligibility for, and communicate with me (by mail, email, fax or phone) about, the Doctors Manitoba CME Rebate Program and any other program related thereto.
- To maintain my personal information in the Doctors Manitoba database.·To develop and market Doctors Manitoba benefit programs, products and services tailored to the interests of physicians, residents/interns, medical students and other eligible purchasers (e.g. family members).
- To represent me and my professional interests, financial and otherwise, through advocacy, negotiation and arbitration.
- To represent the professional interests, financial and otherwise, of physicians through advocacy, negotiation and arbitration.·
- To communicate with me (via mail, text, email, fax or phone) about advocacy, negotiations and arbitration.