Consent to Disclose Personal Health Information v. 1

Record #

Consent to Disclose Personal Health Information

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

 

I,

 

(Print full name: first, middle, and last, or of the Substitute Decision Maker, if necessary)

 

Date of Birth (dd/mm/yyyy):                                                                    SIN #:

 

of

 

(Home address)

Home Telephone:                                                                          Work Telephone:

Authorize       Angel Enrique Pacheco, Ph.D., C.Psych., his Assistants, and/or Associates

 (Health Information Custodians)

 

To disclose

0 My personal health information

0 The personal health information of

 

 

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

(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)

Consisting of:

 

 

(Describe the personal health information to be disclosed)

To

 

 

 

 

(Print full name and address of person and/or institution requiring the information)

 

I understand the purpose for disclosing this personal health information to the person and/or institution noted above.  I have read it, and I understand that I can refuse to sign this consent form or that I can revoke or amend it at any time.  I have signed this consent freely and voluntarily.

 

Signature:

 

Dated (dd/mm/yyyy):

 

Name & Title of Witness (Print):

 

Address of Witness:

 

 

Home Telephone of Witness:                                                                               Work Telephone of Witness:

 

Signature of Witness:

 

 

 

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