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

Дата канвертавання22.04.2016
Памер49.26 Kb.

Name of Patient/Client/Resident:

(Last Name)

(First Name)


Care Card #:

Former Name:


(If Applicable)


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

Day Phone #:

Alternative Phone #:

Mail Delivery

Pick Up (Picture ID required)


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:


Please specify date range of records requested:



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)


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

Name of recipient:


Patient/Client/Resident (or Legal Representative) Signature

Printed Name

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


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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