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
ALSO KNOWN AS / ALIAS
CITY / PROVINCE / COUNTRY
TELEPHONE NO. (INCLUDING AREA CODE) DATE OF BIRTH DAY | MONTH | YEAR
PERSONAL HEALTH NUMBER (CARECARD)
Part 2. Records Requested
EMERGENCY VISIT INFORMATION
DIAGNOSTIC REPORTS (LAB/RADIOLOGY)
OTHER (PLEASE SPECIFY):
PROOF OF VISIT
(fees may apply)
DATE(S) OF RECORDS REQUESTED: ______________________
If you do not know exact dates please provide your best estimate
Part 3. Person Receiving Records
NAME OF COMPANY OR ORGANIZATION (IF APPLICABLE)
OF PERSON RECEIVING THE RECORDS
CITY / PROVINCE / COUNTRY
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
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
PATIENT/REP SIGNATURE (on pickup)
DATE OF RELEASE
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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