Consent to Release Clinical Info

Consent to Disclose Personal Health Information，Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)

PURPOSE: The purpose of the “Consent to release” is to gain the patient’s consent in order to get his/her treatment notes.

HEALTH INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the appointment and treatment.

PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to appointments and treatment.

Your Name

First

Last

information Name Email

I authorize disclosure of:

my personal health information consisting of
the personal health information of

the personal health information to be disclosed

To： Name and address of person requiring the information

I understand the purpose for disclosing this personal health information to the person noted above. I understand that I can refuse to sign this consent form.

My Name

Address

Home Phone

Work Phone

Signature

Clear Signature

Date

Witness Name

Address

Home Phone

Work Phone

Signature

Clear Signature

Date / Time

*Please note: A substitute decision-maker is a person authorized under PHIPA to consent,on behalf of an individual, to disclose personal health information about the individual.

Consent to Release Clinical Info

I understand the purpose for disclosing this personal health information to the person noted above. I understand that I can refuse to sign this consent form.

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