Request for Access to Personal Health Information

Request for Access to
Personal Health Information
You have the right to access (receive a copy or view) the personal health information contained in your record or
the record of a patient for whom you are the Substitute Decision Maker (SDM), if the patient is incapable.
To make a request for access to personal health information, a completed Request for Access to Personal Health
Information form needs to be submitted by mail or fax to the NSM CCAC Health Records Department. To avoid
delays, check that all information is completed on the form and that it is dated and signed. If you are requesting
information as the authorized SDM for a patient who is incapable, you will need to verify your role by providing
the necessary documentation (e.g. copy of Power of Attorney for Personal Care document).
When detailing the personal health information you are requesting to access, specify if you are requesting a
specific document, documents within a time period, documents pertaining to an encounter, or the entire record.
It is advised to include dates and timeframes wherever possible.
Preparation Fee
There is a preparation fee to receive a copy of personal health information. The preparation fee varies with the
size of the release. The invoice will be sent to you with the information requested. The preparation fee is:
• $30.00 for the first 20 pages and $0.25 per page thereafter, or
• $25.00 for a letter (example: confirmation of service)
The preparation fee applies to the patient (or their SDM), or to a law firm, legal aid clinic, advocacy centre,
insurance company or employer requesting information with patient/SDM consent.
Alternatively, the record(s) can be viewed at one of the NSM CCAC offices at no cost.
Response Time
Records will be sent to you by courier within 30 days from the date we receive the fully completed form. If your
request is urgent, please provide rationale on the request form including the date the records are required.
NSM CCAC will contact you if we cannot meet your request timeline.
Contact Us
Please contact the NSM CCAC Health Records Department if you require assistance with this process or if you
have questions regarding:
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•
•
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NSM CCAC privacy policies,
How to access to your personal health information,
How to request a correction of personal health information, or
To identify a privacy issue.
Tel: 705-721-8010 Ext. 6641 or 1-888-721-2222 Ext. 6641
Address: 15 Sperling Drive, Suite 100, Barrie, ON L4M 6K9
Fax: 705-792-6299
North Simcoe Muskoka Community Care Access Centre
Request for Access to Personal Health Information
Please return by fax to 705-792-6299 OR by mail to 15 Sperling Drive, Barrie ON, L4M 6K9, Attention: Health Records
Patient Identification:
Please print
Name: __________________________________________ Date of Birth (yyyy/mm/dd): _________________________
(surname, first name)
Address __________________________________________________________________________________
Postal Code ______________________________ Telephone # ______________________________________
To be completed by patient or authorized substitute decision maker
Request for access:
Receive a copy
View a copy
I, ______________________________________, hereby authorize the North Simcoe Muskoka Community
Care Access Centre to provide access to:
Name of Person/Organization ____________________________ Telephone # __________________
Address _____________________________________________ Fax #
____________________
The following personal health information, relating to above patient: (detail specific information and/or dates)
Authorization By (I have read and understand the Request for Access to Personal Health Information Document)
Name (print) _________________________ Signature: ______________________ Date: ______________
Relationship to patient (check one)
Self
Parent/Guardian
Substitute Decision Maker*
*Please provide documentation supporting that you are an authorized substitute decision maker, if applicable.
For NSM CCAC Use Only:
Client #: ______________________
ROI file #: ___________________________
Notes: __________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
The contents of this telecommunication contains confidential information intended only for the person named. Any other distribution, copying, or disclosure is strictly
prohibited. If you have received this telecommunication in error, please notify us immediately by telephone at 721-8010 or 1-888-721-2222 and return the original
transmission to us by mail without making a copy the event that you fail to receive the entire transmission or encounter any other receipt problems, please contact us.
Request for Access to Personal Health Information
Form # CS-05-22-04/15
Revised April 2015