Consent to Disclose, Transmit, Access or Examine Personal Health Information

Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)

Patient Name:

Date of Birth:

Health Card Number:

Phone Number:

Email Address:

Address (Street / Apt. No. / P.O. Box / R.R. No.):

City/Town:

Province:

Postal Code:

Dates of visit:

Patient records to be disclosed:

Emergency Record

Inpatient Records

Pertinent Medical Information

All Medical Information

Visit History

Other

Recipient Name (if the requestor is not the patient):

Recipient Phone Number:

Recipient Fax Number:

Recipient Email Address (if different than above):

Recipient Address (Street / Apt. No. / P.O. Box / R.R. No.):

Recipient City/Town:

Recipient Province:

Recipient Postal Code:

I understand that this personal health information is to be used only by the recipient for the purposes of:

Personal

Lawyer

Insurance

Other

As the patient or substitute decision-maker, I authorize William Osler Health System to disclose the aforementioned health information to the recipient indicated for the purpose(s) listed.

I am a patient

I am a substitute decision-maker

As part of your request, you must provide the following three images:

A photo of your green Ontario heath card on its own
A photo holding your Ontario health card by your face, to confirm identity (like a selfie)
A photo of a second piece of government-issued photo ID on it is own (preferably a driver’s license, Ontario photo card or passport)

If requesting on behalf of a patient, you will also be required to provide your proof of Power of Attorney.

Please upload your three photo files and your proof of Power of Attorney (if applicable):

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Signature:

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Date:

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Consent to Disclose, Transmit, Access or Examine Personal Health Information

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