RELEASE OF INFORMATION DEPARTMENT
St. Joseph’s Health Centre
30 The Queensway, Toronto, ON, M6R 1B5
Tel: 416-530-6047 / Fax: 416-530-6046
Email: ROI@stjoestoronto.ca
*A substitute decision maker is a person authorized under the Personal Health Information Protection Act to consent, on behalf of an individual, to
For Release of Information Office use only:
Request #: _____________________
Chart #: ___________________
____
CONSENT TO DISCLOSE PERSONAL HEALTH INFORMATION
I,
________________________________________________, hereby authorize
(First name, last name)
ST. JOSEPH’S HEALTH CENTRE TORONTO to disclose the following personal health information:
_________________________________________________________________
_________________________________________________________________
(Describe the personal health information to be disclosed – include treatment date & types of reports)
From the record of:
NAME:_____________________________________________________________
(Your own name if it is your record, or the name of the person for whom you are the substitute decision-maker)*
DATE OF BIRTH: _____________________
(DD / MM / YYYY)
HEALTH CARD NUMBER: _______________
ADDRESS:___________________________________________________________
To the following individual or facility:
Personal Lawyer
Insurance Care provider
Other:___________________
RECIPIENT NAME: _____________________________________________________
(Name of person, family member, doctor, hospital, insurance, etc. who is to receive the personal health information)
ADDRESS:___________________________________________________________
PHONE NUMBER:____________________ FAX NUMBER: ______________________
Print: Patient Name/Substitute Decision Maker
___________________________
Print: Name of Witness
___________________________
Signature & Relationship:
___________________________
Signature of Witness
___________________________
Date:
___________________________
(DD / MM / YYYY)
disclose personal health information about the individual.
Please note that Photo I.D. is requir
ed to confirm identity. The consent form is valid for a period of three months from the date the form is signed.
P000201(Health Records)-JUNE-2020
