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Sample Consent Form to Disclose Personal Health Information

Purpose

Key Questions: What are the required elements of a consent form to disclose Personal Health Information?

This tool provides a template and overview of what goes into a Consent Form to Disclose Personal Health Information and can be adapted to suit your organization's needs. This form is pursuant to the Personal Health Information Protection Act (PHIPA), 2004.

Generally, health information custodians must obtain your consent to collect, use and disclose your personal health information, unless the Personal Health Information Protection Act (PHIPA), allows for the collection, use or disclosure without your consent, as in the case of a medical emergency. This form gives express consent to disclose personal health information. 

Contents

  • Consent to Disclose Personal Health Information
Contact Person/Organization: 

SupportNet.ca

Type of Tool:

Publication Date: 
Unknown
Videos: 

PHIPA - GETTING TOUGH ON PRIVACY NON-COMPLIANCE