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Health Information Protection Act, 2004

Sample Consent Form : Authorization to Disclose Personal Health Information

Each time someone visits a healthcare provider, has a test done or receives care in their home, the hospital or other healthcare setting, information about their health is recorded in a personal health record.

On November 1, 2004, the Personal Health Information Protection Act, 2004 (PHIPA) came into force. This new law sets out rules that "health information custodians" must follow when collecting, using and sharing someone's personal health information. Health information custodians include health care providers, such as doctors, nurses and dentists, and others involved in the delivery of healthcare services, including pharmacies, medical laboratories or local medical officers of health.

The Ministry of Health and Long-Term Care is providing a sample Consent to Disclose Personal Health Information form. This form may be used by a health information custodian to authorize a disclosure of a patient's personal health information to another person. The consent form specifies with whom the personal health information may be shared; it could be with another health care provider, or, for example, with a school board, an insurer or a lawyer.

This sample form is provided in two formats for your convenience. The Microsoft Word format is provided so that you may change it to suit your needs. For example, you may wish to insert your letterhead. Or, you may prefer the PDF format, which can only be used, as is.

Document download
MICROSOFT WORD Format
Consent to Disclose Personal Health Information
Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)
PDF Format
Consent to Disclose Personal Health Information
Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)

To view PDF format files, you need to have Adobe Acrobat® Reader installed on your computer.
Download Acrobat Reader   You can download this free software from the Adobe Web site.
 
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TTY 1-800-387-5559
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