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)




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


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




(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)






(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.




Dated (dd/mm/yyyy):


Name & Title of Witness (Print):


Address of Witness:



Home Telephone of Witness:                                                                               Work Telephone of Witness:


Signature of Witness:



 We are here to help you…

 Learn to Live Better ®