Consent To Disclose Personal Health Information printable pdf download

Consent To Disclose Personal Health Information

Consent to Disclose Personal Health Information

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

____________________________,

______________________________

authorize

(Print your name)

(Print name of health information custodian )

to disclose

□

my personal health information consisting of:

_____________________________________________________________________________

(Describe the personal health information to be disclosed)

□

the personal health information of _________________________________________

(Name of person for whom you are the substitute decision-maker

)

consisting of:

___________________________________________________________________

______________________________________________________________________________

(Describe the personal health information to be disclosed)

_____________________________________________________________________

(Print name and address of person requiring the information)

I understand the purpose for disclosing this personal health information to the person

noted above. I understand that I can refuse to sign this consent form.

My Name:________________________ Address:____________________________________

Home Tel.:________________________ Work Tel.:

________________________________

Signature:_________________________Date:_______________________________________

Witness Name:_____________________Address:____________________________________

Home Tel.:________________________ Work Tel.:________________________

______

Signature:_________________________Date:_______________________________________

Please note: A substitute decision-maker is a person authorized under PHIPA to consent,

on behalf of an individual, to disclose personal health information about the individual.

Consent To Disclose Personal Health Information