Form Phc-Mr091 - Authorization For The Release Of Health Records

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AUTHORIZATION FOR THE RELEASE OF HEALTH RECORDS

Please fax or mail your completed request to each hospital/facility you are requesting records from.

ATTENTION: Health Information Management, Release of Information Office

Part 1. Patient / Resident Information

LAST NAME OF PATIENT

FIRST NAME

ALSO KNOWN AS / ALIAS

MAILING ADDRESS

CITY / PROVINCE / COUNTRY

POSTAL CODE

TELEPHONE NO. (INCLUDING AREA CODE) DATE OF BIRTH DAY | MONTH | YEAR

PERSONAL HEALTH NUMBER (CARECARD)

| |

Part 2. Records Requested

HOSPITAL(S)/FACILITY:

□

VISIT SUMMARY

EMERGENCY VISIT INFORMATION

DIAGNOSTIC REPORTS (LAB/RADIOLOGY)

□

ALL or

OTHER (PLEASE SPECIFY):

PROOF OF VISIT

(fees may apply)

DATE(S) OF RECORDS REQUESTED: ______________________

TO ___________________________________________

If you do not know exact dates please provide your best estimate

Part 3. Person Receiving Records

□

NAME OF COMPANY OR ORGANIZATION (IF APPLICABLE)

MYSELF OR

NAME

OF PERSON RECEIVING THE RECORDS

(LAST, FIRST)

MAILING ADDRESS

CITY / PROVINCE / COUNTRY

POSTAL CODE

□

TELEPHONE NO. (INCLUDING AREA CODE)

(Picture ID Required)

RECORDS TO BE:

MAILED □ PICKED UP

Part 4. Patient Authorization

(12 years of age or older)

I, the patient, authorize the Hospital(s)/Facility to release the records requested to the person named in the “Person Receiving

Records” section.

SIGNATURE OF PATIENT: ___________________________________________ DATE SIGNED: ____________________________

Part 5. Authorization on behalf of Patient (Please complete page 2 of form)

(If patient is under 12 years of age or unable to authorize the release of personal information.)

By signing below I confirm that I have legal authority to act on behalf of the patient and I hereby authorize the

Hospital(s)/Facility to release the records requested to the person named in the “Person Receiving Records” section.

□

I have indicated my relationship to the patient on page 2 of this form; and

□

If applicable, I have attached documentation to show my status as legal representative or guardian (e.g. copy of will, court

order, legal agreement, or other documentation).

REASON FOR REQUEST: ______________________________________________________________________________________

YOUR FULL NAME: __________________________________________________________________________________________

YOUR SIGNATURE: _________________________________________________ DATE SIGNED: ___________________________

Internal Use Only

ID OBSERVED:

PATIENT/REP SIGNATURE (on pickup)

DATE OF RELEASE

STAFF INITIAL

□

Other: (specify) __________

This authorization must be signed by the patient/resident/authorized representative and must be dated within 6 months of the request being submitted.

The BC Freedom of Information and Protection of Privacy Act (FIPPA) allows (30) business days to respond to all requests.

Personal Information contained on this form is collected under s. 26(c) of FIPPA and will be used only for the purpose of responding to your request. If you

have questions please contact the Health Information Management Release of Information Office.

Form No. PHC-MR091 (Aug 26-15)

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