Withdrawal of Consent to Disclose Personal Health Information

Record #

Withdrawal of 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:

 

0  Wish to withdraw my consent to any further use or disclosure of

     o  My personal health information

     o  The personal health information of

or

0  Wish to place the following conditions on any further use or disclosure of

     o  My personal health information

     o  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)

 

 

 

(Please specify conditions, if applicable)

By the Health Information Custodians:

 

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

(Health Information Custodians)

 

I understand that this withdrawal of consent does not have retroactive effect nor does it affect the uses and disclosures of personal health information collected by Angel Enrique Pacheco, Ph.D., C.Psych., his Assistants, and/or Associates where the uses and disclosure are permitted or required by law without consent.

 

I have read this Withdrawal of Consent, and I understand that I can revoke or amend it at any time.  I have signed this Withdrawal of 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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