Request for access / release of patient/client/resident records




Дата канвертавання22.04.2016
Памер49.26 Kb.
REQUEST FOR ACCESS / RELEASE OF PATIENT/CLIENT/RESIDENT RECORDS
CONTACT INFORMATION:













Name of Patient/Client/Resident:
















(Last Name)

(First Name)




Birthdate:




Care Card #:




Former Name:










(dd/mm/yyyy)










(If Applicable)




Address:










(P. O. Box/Street, City & Postal Code – including country if outside of Canada)




Day Phone #:




Alternative Phone #:





































Mail Delivery

Pick Up (Picture ID required)





SITE:






















Victoria General Hospital

Nanaimo Regional General Hospital

Campbell River Hospital




Royal Jubilee Hospital

Cowichan District Hospital

Tofino General Hospital




Eric Martin Pavilion

Ladysmith Community Health Ctr

Port Alice




Saanich Peninsula Hospital

Ladysmith Family Practice

Port Hardy




Queen Alexandra Centre

West Coast General Hospital

Port McNeill




Health Point Care

Oceanside Health Centre

Lady Minto Hospital

Cormorant Island





Mental Health and Addictions (name of service):







Public Health (name of agency):







Home & Community Care (name of health unit):







VIHA Residential Care Facility:







Other Site:








RECORDS REQUESTED:






















Please specify date range of records requested:



















(from)

(to)




Outpatient Records

Medical Imaging (Reports X-ray, MRI/CT scan, Ultrasound)

Medical Imaging CD




Inpatient Records

Emergency Records




Discharge Summary

Results of blood tests & other lab work




Physician History/Consultation

Pathology Reports




Operative/Procedural Reports

Therapy Assessments (may include Physiotherapy/Occupational Therapy/Nutrition)




Other Records:







Deceased’s Records (reason for request):










Must attach first & last page of Will (consent from Executor required if applicant is not the Executor)





AUTHORIZATION:

I request that the above information be provided to me at the above address or to:




Name of recipient:
















Address:































Patient/Client/Resident (or Legal Representative) Signature




Printed Name































Relationship to Patient/Client/Resident if signed by Legal Representative




Date







Please note - In the case of a legal representative signing the authorization, proof of authority to act on the patient/client/resident’s behalf, (e.g. copy of Personal Representative Agreement) must be attached. If requesting on behalf of a child, consent from the child may be required.

This authorization will expire six months from the above date. Requests for further records will require a new form. (Statutory Provisions relevant to this request: Freedom of Information and Protection of Privacy Act s.4 and s.5)



PLEASE NOTE – Unless notified, response will be within 30 business days (as per FIPPA s.7) Release of Pt. Records Form - Oct 2013


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