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