Request to Correct Personal Health Information

Required fields are marked with asterisks (*)
Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA). Personal Health Information contained on this form is collected pursuant to the Personal Health Information Protection Act, 2004 (“the Act”) and will be used for the purpose of responding to your request for correction pursuant to section 55 of the Act.

Requestor's Information

Full Name*

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

City/Town*

Province*

Postal Code*

Phone Number *

Email Address *

Substitute Decision-Maker Information

Please provide documentation to satisfy the health information custodian that you are an authorized substitute decision-maker.

Full Name

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

City/Town

Province

Postal Code

Phone Number

Email Address

Please provide a detailed description of the personal health information to which access has been granted and that you are requesting be corrected, the reasons that the personal health information is incomplete or inaccurate and the information necessary:*

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

Signature:*

Date*

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