Access Request for Personal Health Information

Section A - Personal Health Information Details

Type of Request (Select One):

Access to my own personal health information

Access to another’s personal health information by an authorized party

Department:

Public Health

Paramedic Services - Ambulance Call Report

Seniors Services

Early Intervention Services

Name of person whose personal health information is being requested

First Name:

Last Name:

Date of Birth:

Date Range:

Description of Information:

(Please specify details, e.g., program name, document name and date range. For Ambulance Call Reports, please specify incident circumstances.)

Location and Time of Accident:

(Ambulance Call Report Request Only)

Section B - Requester Details

I am the individual whose personal health information is being requested

I am the parent with custody, or a person lawfully entitled to consent on behalf of the individual.

Requester First Name:

Requester Last Name:

Phone Number:

Email Address:

Please ensure the email address provided is accurate, as a complete submission notification will be sent to this address.

Date:

By checking this box, I confirm that the information provided is accurate and complete to the best of my knowledge, and I acknowledge that this electronic confirmation is the legal equivalent of my signature.

Section C - Consent for Disclosure by Encrypted Email

If you would like the requested information disclosed to you by encrypted email, please review the consent information below and provide an email address to release the information.

I authorize the Community and Health Services - Privacy Office to release the above noted personal health information by an encrypted email to myself and/or a third party (if applicable)
I understand there are risks associated with email communication. Sending personal health information by encrypted email does not guarantee complete security, and the information could be inappropriately accessed by others
I understand that I have the right to withdraw consent at any time by contacting @email. Withdrawal of consent does not have a retroactive effect
I have been given an opportunity to ask questions related to this consent form and my questions were answered

How would you like to receive the encrypted email?

To the email address specified in Section B

To a different email address

To the email specified in Section B and an additional email address

Please enter the email address:

Please ensure the email address provided is accurate, as a complete submission notification will be sent to this address.

Section D - Supporting Documents

In addition to your request, please provide supporting documentation based on the type of access request you select.

Requesting your own information

A copy of your driver’s license or another government issued photo ID

Requesting information on behalf of another individual

If you're requesting information on behalf of your child (under 16) where there is a custody arrangement, please upload:

A court order or custody agreement setting out the custody arrangements
A copy of your driver’s license or another government issued photo ID

If you're requesting information on behalf of another individual, please upload:

If the individual has capacity, consent from the individual in writing authorizing the requestor (over 16 years of age) to act on the individual’s behalf

If the individual does not have capacity, consent of the individual’s substitute decision-maker, as authorized in accordance with PHIPA and/or other applicable law

A copy of the requestor’s driver's license or another form of government issued photo ID

If you're requesting information on behalf of a deceased individual, please upload:

Documentation verifying requestor is the deceased's estate trustee, or that they have authority to administer the deceased's estate;
- If more than one individual has been named as the deceased's estate trustee, consent may be required from both or all individuals
A copy requestor’s driver’s license or another form of government issued photo ID

Law Firms

The complete access request form or the formal request letter on letterhead
Consent from client

Please upload the required document(s) based on your request type:

Maximum 20 files.
16 MB limit.
Allowed types: pdf, jpg, jpeg, png, heic, heif, doc, docx, gif.

Access Request for Personal Health Information

Notice of Collection

Section A - Personal Health Information Details

Section B - Requester Details

Section C - Consent for Disclosure by Encrypted Email

Section D - Supporting Documents