Release Of Information Request Form - Pictou County Health Authority Page 2
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26.
Fee Schedule: (as set out in Regulations in the Personal Health Information Act (PHIA))
•
There is no fee to have records sent directly to a regulated healthcare provider for ongoing health care purposes.
•
There is a $30.00 + HST administrative fee, plus photocopying fees to request records for any reasons other than for a regulated
healthcare provider. Additional fees may apply (depending on size of request, shipping requirements, procurement from offsite
storage, etc.)
7.
Relationship to the patient: (please check one)
Self
Substitute Decision Maker
Other
Pictou area staff will require proof of authority to access patient/client information and will require ID to verify an individual’s identity to
access information, before disclosing health information. Please be ready to show identification (ID should be a government issued photo ID
or 2 pieces of alternate ID with signatures) to Pictou area staff. If you are mailing/faxing this form, please enclose a clear photocopy of your
ID as described.
SIGNATURE: (Required for all requests)
I give permission to Nova Scotia Health Authority (hospital or service chosen on the reverse side of form) to disclose the
requested health information to myself/Substitute Decision Maker and/or the person or organization named in Section 3.
Patient Signature:
____________________________________
Date: _______________________
Substitute Decision Maker:
____________________________________
Date: _______________________
Signature of Witness:
____________________________________
Date: ________________________
8.
To be completed ONLY when applicant cannot provide proof of identity
I, _______________________________________ (print FULL name) certify that the applicant ________________________________
(print FULL name ) has been known to me personally as a _______________________ (insert in what capacity, e.g. employee, client,
patient, etc.) for ______ years, and that I witnessed him/her complete and sign the attached Authorization for Access/Disclosure of Health
Information form.
Daytime Phone #: _________________________
Signature _______________________________________ Date: (dd/mm/yyyy) _________________________
9.
For Release of Information OFFICE use only:
Date Request Received
__________________________
Signature of Staff Releasing Info:
(1) _____________________________________________________________
(2) _____________________________________________________________
Date Disclosed
___________________________
Requester’s ID verified?
Type of ID provided: _________________________
Recipient’s ID verified?
Type of ID provided: _________________________
(*only applicable if Recipient named in part 4 picks up records in person)
c:FormsRELEASE OF INFORMATION REQUEST FORM-01-04-15
Revised: April 1, 2015
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