Ministry of Health Healthy Smiles Ontario

Healthy Smiles Ontario

33 King St W
PO Box 645
Oshawa ON L1H 8X1

HSO Reference No. L0231487008

Consent Form
This Consent Form provides the signed consent required for the Ministry of Health to complete
the processing of your application for the Healthy Smiles Ontario program (“the Program”).

For more information, please visit ontario.ca/healthysmiles or contact the ServiceOntario

INFOline:

Toll-free: 1 844 296-6306

TTY toll-free: 1 800 387-5559

416 327-4282 (TTY Toronto only)

Section 1 Terms and Conditions

This Consent form requires the applicant, and if applicable the spouse/common law partner, to accept the Terms and
Conditions below.

I declare that:

• The children/youth(s) for whom this Healthy Smiles Ontario Application form is being made meet the following
eligibility requirements for the Healthy Smiles Ontario Program ("the Program"):
• ​17 years of age or under;
• live in Ontario; and
• the household they live in meets the income eligibility requirements as indicated at
ontario.ca/healthysmiles

• I have not misrepresented information about myself or my household and understand that any misrepresentation
may result in the immediate removal of children/youth(s) from the Program, and that the Government of Ontario may
seek reimbursement for any services that were rendered while the children/youth(s) were ineligible for the Program.
I understand that the information on this Application form may be subject to audit and verification. I must
immediately report any changes that may affect the eligibility of the children/youth(s) to the Ministry of Health. The
mailing address given on the Application form will be the address used for all household members listed.

• I understand that only certain dental procedures are covered under the Program, as listed in the Healthy Smiles
Ontario Program Schedules of Dental Services and Fees. I am responsible for paying for services not covered or
paid for under the Program, and for any services rendered after the end date of the children/youth(s) eligibility
period.

Enquiries 1 844 296-6306 ontario.ca/healthysmiles

Teletypewriter (TTY) 1 800 263-7776
 • I understand that any existing public or private dental insurance coverage for children/youth(s) listed must be utilized
before resorting to the Program. I understand that if any children/youth(s) listed have other insurance coverage, I
may be asked to send further information from the Insurance carrier.

• I understand that the children/youth(s) eligibility end date is the earlier of the following: either July 31 following the
date of the application or the 18th birthday of the children/youth(s). I understand that the Ontario Ministry of Finance
will re-confirm that the children/youth(s) continue to meet the eligibility requirements of the Program following the
Program eligibility period end-date each benefit year (July 31).

• I understand that the Ontario Ministry of Finance, on behalf of the Ministry of Health, will keep my Application
information on record for the purpose of annual eligibility verification.

• I understand that I must re-apply to the Program if I did not file taxes in the most recent tax year(s) based on which
eligibility is being verified. Upon completion of the verification process, the Ministry of Health will issue the eligible
children/youth(s) a renewed dental card.

• I understand that the dental card is valid for up to one benefit year (August 1 – July 31) from the registration date
and will expire at the end of each benefit year (July 31) or the 18th birthday of the children/youth(s) listed.

• I understand that the dental card must be presented to the dental provider at each visit in order to obtain services
under the Program. Dental providers will not render services under the Program unless a valid dental card is
presented.

• I also understand that the Ministry of Health collects the information I have provided on the application form for the
purpose of evaluation to ensure that the Program meets the needs of eligible children and youth.

Notice of Collection: The personal information collected on this form will be used by the Ontario Ministry of Health, Ontario Ministry of
Finance, and ServiceOntario for the purpose of determining eligibility under the Healthy Smiles Ontario Program (the “Program”) and
otherwise administering the Program. The Ontario Ministry of Finance’s authority to collect and share personal information with the
Ministry of Health and ServiceOntario is in section 11 of the Ministry of Revenue Act which authorizes the Ontario Ministry of Finance
to assist other ministries in administering a government assistance program. The personal information collected on this form will only
be used and disclosed for the purpose of administering the Program, or otherwise in accordance with applicable law. For more
information about this collection, please contact the Director, Health Promotion and Prevention Policy and Programs Branch, Ministry
of Health, 393 University Avenue, Suite 1802, Toronto ON M7A 2S1 or call 416 314-2257.

Section 2A Consent for Ministry of Health, Ontario Ministry of Finance and ServiceOntario to collect,
use and disclose my personal information
I understand that the personal information that I provide on this form is collected by the Ministry of Health, the Ontario
Ministry of Finance and ServiceOntario, for the purpose of administering the Program. I understand that the Ontario
Ministry of Finance and ServiceOntario are assisting the Ministry of Health with the administration of this government
program.

I consent to the Ministry of Health, the Ontario Ministry of Finance and ServiceOntario, sharing information that relates to
eligibility under the Program with one another, for the purpose of administering and processing my file.

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 Consent for the Ontario Ministry of Finance to disclose personal information to the
Section 2B Canada Revenue Agency and Consent for the Canada Revenue Agency to release my tax
information to the Ontario Ministry of Finance
I consent to the disclosure of this personal information by the Ontario Ministry of Finance, on behalf of the Ministry of
Health, to the Canada Revenue Agency, for the purpose of enabling the Ontario Ministry of Finance and the Ministry of
Health to administer the Program, which includes determining eligibility, issuing letters and notices, and responding to
inquiries about my file.

I consent to the disclosure by the Canada Revenue Agency to the Ontario Ministry of Finance, my income and expense
information and related identifying information about me from the Canada Revenue Agency tax records, on condition that
the information will be used solely by the Ontario Ministry of Finance to verify my income and eligible dependents, and to
determine eligibility under the Program. This authorization is valid for the two taxation years immediately preceding the
date of application and each subsequent taxation year(s) for which eligibility under the Program is determined.

I understand that this consent will remain in effect until it is withdrawn, that it can be withdrawn in writing and that if the
consent is withdrawn, this may affect eligibility under the Program.

Section 3 Consent for Collection, Use and Disclosure of Personal Health Information

This section asks for your consent to allow the Ministry of Health, the children/youth(s) dental service providers and local
public health units to collect, use and disclose certain personal health information (i.e. treatment data) about the
children/youth(s) related to the Healthy Smiles Ontario Program (“the Program”) in order for the Ministry of Health to
administer and evaluate the Program.

The children/youth(s) cannot obtain dental services under the Program if you do not consent to the collection of the
children/youth(s) personal health information. You can withdraw your consent at any time in writing. Please note that your
withdrawal will have no effect on the personal health information disclosed to the Ministry of Health before the date of the
withdrawal; however, the Ministry of Health will only use or disclose that personal health information as permitted or
required by the Personal Health Information Protection Act, 2004.

I consent to:

1. The Ministry of Health disclosing the children/youth(s) enrollment status to the children/youth(s) dental service
provider and local public health unit for the purpose of confirming the children/youth(s) enrollment in the Program,
where approved.

2. The Ministry of Health disclosing the children/youth(s) name, date of birth, and children/youth(s) identification
number to the children/youth(s) dental service provider and local public health unit, as applicable, so that:

• ​the children/youth(s) dental service provider and local public health unit, as applicable, can locate the
children/youth(s) treatment information for this Program and provide it to the Ministry of Health.

3. The children/youth(s) dental service provider and the children/youth(s) local public health unit, as applicable,
disclosing the following personal health information to the Ministry of Health so that the Ministry can use the
personal health information to administer, audit and evaluate the Program:

• The children/youth(s) treatment information such as services provided to the children/youth(s), the
children/youth(s) tooth and surface number, the name of the children/youth(s) dental provider, and service date.

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I understand:

• That the disclosure of the children/youth(s) personal health information will continue until I withdraw my consent;

• This consent will remain in effect until it is withdrawn, and that if the consent is withdrawn, this will affect eligibility
under the Program;

• That the Ministry of Health will collect, use and disclose the children/youth(s) personal health information as
permitted or required by the Personal Health Information Protection Act, 2004;

• That I can withdraw my consent at any time in writing; and

• That my withdrawal will have no effect on the personal health information collected by the Ministry of Health before
the date of my withdrawal.

I consent for all the purposes listed above (Sections 1, 2A, 2B and 3).

Name of Applicant Date

Yared Gesese [[d|1 ]]
Signature of Applicant

[[s|1 ]]
Name of Spouse/Common Law Partner (if applicable) Date
Yengus Abeje [[d|2 ]]
Signature of Spouse/Common Law Partner (if applicable)

[[s|2 ]]
Please sign this form for your application to be processed.

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