Consent to Disclose Personal Health Information v. 2

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

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

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

(Health Information Custodians 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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