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Work Ready CBT Authorization Form

AUTHORIZATION & RELEASE FORM

Confidential Client Code:

I (client name) hereby authorize the release of information concerning my Banyan Work Ready CBT

Program. I authorize Arete® Human Resources Inc. on contract to Banyan Work Health Solutions Inc. and their affiliates to collect,

use and exchange any information about me that is relevant to my group disability claim for the purpose of planning and managing

my rehabilitation and return to work.

Disclosure to other health care providers: In the process of administering your file, relevant health information may be shared with

health care providers involved in your care, including (but not limited to) physicians and specialists, nutritionists, kinesiologists,

psychologists, counsellors, physiotherapists and occupational therapists.

Disclosure to Employer: In the process of administering your file, if indicated, information regarding return to work planning along

with your functional abilities related to work may be disclosed to your employer and union. All information shared with your

employer would be strictly related to function and your ability to perform your job. No details of diagnosis, treatment, medication or

specialists would be shared with your employer.

I recognize that my insurer will receive progress reports and is privy to some information pertaining to my progress in order to

better manage my disability case file.

This authorization document is valid as long as my file is active with Arete® Human Resources Inc. All parties will keep all personal

information strictly confidential and in compliance with the Personal Information Protection and Electronic Documents Act.

I am responsible for the full cost of no shows and less than 24 hour notice cancelled/changed appointments.

Signature of client: Signature Date:

Counsellor Signature:

A photocopy of this document will have the same validity as the original.

Please email or fax the completed form to Arete® Human Resources Inc. at 403-252-6161(fax) or klee@aretehr.com (form updated 12-7-12)