Osler
Forms
Freedom of Information Request and Correction of Personal Information
Required fields are marked with asterisks (
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Personal Information contained in this form is collected pursuant to the Freedom of Information and Protection of Privacy Act (FIPPA) and will be used for the purpose of responding to your request for access or correction of personal information in accordance with sections 10 and 47 of the Act. Questions about this collection or about the response process in general should be directed to the Freedom of Information and Privacy office by calling 905-494-2120 ext. 29466.
Request for
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Access to General Records
Access to Personal Information
Correction to Personal Information
Full Name
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Please include the last name appearing on records:
Address (Street / Apt. No. / P.O. Box / R.R. No.)
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City/Town
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Province
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Postal Code
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Telephone Number
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Email Address
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Detailed description of requested record(s) or personal information to be corrected. If access to or correction of a specific personal record(s) is requested, please identify the record(s):
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Request for
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Examine Original
Receive Copy
If requesting access to or correction of personal information, you must provide the following:
A photo of your valid government-issued photo identification, by itself. (e.g., driver’s license, Ontario photo card, passport)
A photo of you holding your valid government-issued photo identification beside your face to confirm your identity
If requesting personal information on behalf of a patient or visitor, in addition to the above, please also submit:
A consent form, letter or email from the respective person to whom the information pertains
A photo of the person’s government-issued photo identification
If the person is deceased, we require documentation that validates your position of estate trustee or administrator of the estate
If requesting a correction to personal information, please upload any additional supporting documentation
Please upload your files:
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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif
Signature:
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Clear
Date
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Submit
