Law Enforcement Agencies - York Region Paramedic Services Access Request for Personal Health Information

Information is being collected and will be retained, used, disclosed and disposed in accordance with the Personal Health Information Protection Act, 2004, S.O. 2004. For more information about our information practices, please visit privacy and disclaimer. Any questions regarding this collection may be directed to @email or 1-877-464-9675 ext. 73007

Section 1 - Incident Information

Patient First Name:

Patient Middle Name:

Patient Last Name:

Patient Date of Birth:

Incident Date:

Incident Location Street Name:

Incident Location City:

Alternative Reference Point to Incident Location:

Incident Approximate Time:

Section 2 - Requesters Information

Requester Agency Name:

Occurrence File Number:

Badge Number:

Requester First Name:

Requester Last Name:

Phone Number:

Extension (if applicable):

Contact Information

Please enter the email address where you would like to receive the requested records.

Type of Documents Requested

Please select the type of document you would like to request:

Ambulance Call Report

Incident Report

Additional information:

Please provide a brief incident history and any other supporting documentation, if applicable.

Please upload any supporting documentation (if applicable):

Unlimited number of files can be uploaded to this field.
16 MB limit.
Allowed types: gif, jpg, png, txt, pdf, doc, docx, heic, heif.

Authority for Request

Please select the reason for your request:

To aid an investigation undertaken with a view to a law enforcement proceeding or there is a reasonable basis to believe that an offence may have been committed and the disclosure is to enable determination of whether to conduct such an investigation.

(Personal Health Information Protection Act, 2004, sect. 43(1)(f); Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, sect. 32(g).

To comply with a summons, order, procedural rule, or similar requirement that requires the production of the information.

(Personal Health Information Protection Act, 2004, sect. 41(1)(d)(i) and (ii)).

To carry out an inspection, investigation, or similar procedure that is authorized by a warrant, PHIPA, or any other statute, for the purpose of complying with the warrant or to facilitate the inspection, investigation or similar procedure.

(Personal Health Information Protection Act, 2004, sect. 43(1)(g)).

For the purpose of eliminating or reducing a significant risk of serious bodily harm to a person or group of persons.

(Personal Health Information Protection Act, 2004, sect. 40(1)).

Acknowledgement

By checking this box, I confirm the information being requested is for a law enforcement investigation being conducted by the Agency.

Date: