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Patient and Visitor Privacy Complaint Form

Please complete this form to submit a complaint to Osler's Privacy office if you have been notified of or experienced any of the following:

I have reason to believe that one or more of the following has occurred:

Osler has inappropriately collected personal health information

Osler has inappropriately disclosed personal health information

Osler has inappropriately disposed of personal health information

Other

Details of the complaint

Please provide a detailed description of your privacy complaint covering the what, when, who, how, where and why of what happened in the space below:

Full Name:

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

City/Town:

Province:

Postal Code:

Phone Number:

Phone Number (alternate):

Complete only if you are completing on behalf of a patient.

Full Name:

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

City/Town:

Province:

Postal Code:

Phone Number:

Phone Number (alternate):

Relationship to patient:

Your signature is your consent for Osler to investigate your complaint.

Signature:

Clear

Date: