Consent Authorize Personal Health Information

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

Health Card ID #

Date of Birth

authorize

To Disclose

my personal health information consisting of

(Describe the personal health information to be disclosed)

or

the personal health information of

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

Consisting of

to
(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

My 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

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

To Disclose

or

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.

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