Release Of Information Request Form - Pictou County Health Authority

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Authorization for Release of Health Information
Release of Information Office
Aberdeen Hospital
835 East River Road, New Glasgow, NS B2H 3S6
Tel: (902) 752-7600 ext 6260
Fax (902) 752-2332
1. PATIENT/CLIENT IDENTIFICATION INFORMATION: (Please print)
Last Name:
First Name:
Middle Initial:
Address:
Previous Surname:
Date of Birth:
(Year/ Month/ Day)
Health Card or Provincial Insurance Number:
Daytime Telephone Number:
2. I REQUEST: (Please check one)
 To view the original record
 A copy of the original record or specific documents (As noted in Section 4)
3. Information Requested From:
 Hospital
 Program/Service and/or Individual
4.
DISCLOSE INFORMATION TO: (Please check one)
 I am requesting access to the record OR
 I authorize the disclosure of information to the following person(s): (Name of person/organization to receive the information)
Person/ Organization: _____________________________________________________________________
Address: _______________________________________________________________________________________________________
Telephone # _____________________________________ Fax # ___________________________________
** Please note this person will be asked to show photo ID if picking up records in person**
I authorize Pictou area staff and physicians to verbally discuss my personal health information with the above – named
person/organization.
5.
MY AUTHORIZATION FOR DISCLOSURE IS LIMITED TO THE FOLLOWING INFORMATION: (check all that apply)
 Verification of Dates
 Verification of Birth
(include Mother’s full name, date of birth, child’s full name and date of birth)
 All Records
(Inpatient/Client and/or Outpatient/Client care)
 Specific records
(List specific records requested & relevant dates (e.g. Emergency records from xx date or physiotherapy records from xx to xx date)
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c:FormsRELEASE OF INFORMATION REQUEST FORM-01-04-15
Revised: April 1, 2015

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