REQUEST FOR ACCESS TO PERSONAL INFORMATION
The information on this form will be used to respond to your request
for your personal information or the personal information of someone
whom you are legally entitled to represent.
Whose information do you want access to?
- My own personal information.
- Another person’s personal information.
Please complete the “Patient Information” and “Authorized
Representative’s Contact Information”sections below,
and attach proof that you can legally act on behalf of that individual.
Patient information
Mr / Mrs / Ms (please circle) Street address: _____________________________________
Last name:__________________________________ City /town: ______________________________
Prov.______
First name: _________________________________ Postal code: ___________________
Fax:_________________
Health Card number: _________________________ Tel: (home) _____________________
(bus) _________________
Date of birth (dd/mm/yy): ______________________ Email address:
_______________________________________
Please describe, in as much detail as possible, the information
you want access to. Indicate if you also want access to records
about the disclosure of your information, or information of the
person you are representing. Be sure to give previous names, if
any.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please indicate if you wish to:
- Receive a photocopy of the record.
Please note that a base fee of $______ per page applies for each
page copied. For convenience, you may enclose this fee with your
request. You will be provided with an estimate of any additional
costs.
- View the original record, without receiving a copy.
Please ask for an estimate of the fee you will be charged for:
- Review of the original by the physician and / or
- Supervision by physician or designated staff person for your
review
A deposit of the fee(s) may be required.
X______________________________________ _________________________________________
Patient Signature
Date (dd/mm/yy)
*Click
here to print the PDF version of this form
Click here for "Access by
Authorized Representative" form
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