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

Required fields are marked with asterisks (*)

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

Personal information

Patient Full Name*

Date of Birth*

Phone Number*

Health Card Number

Dates of visit

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

Email Address*

City/Town *

Province *

Postal Code *

Patient records to be disclosed*

Emergency Record Pertinent Medical Information Visit History Inpatient Records
All Medical Information 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): * Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Signature:*

Date*

Osler Forms

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