Fillable Consent to Release Information (College of Physicians & Surgeons of Alberta)

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Consent to Release Information (College of Physicians & Surgeons of Alberta)

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I understand my signature on this release will allow the College of Physicians & Surgeons of
Alberta (CPSA) to do the following in order to investigate certain matters under the Health
Professions Act:
1. Get medical records or other information about my complaint issue(s). Note: medical
recordsincludepersonidentiableinformation,diagnostic,treatmentandcare
documentation.
2. Give a copy of my complaint to the physician(s) named and all other persons who provide
information.
3. Share,whereapplicable,informationconcerningmycomplaintincludingpersonidentiable
information,diagnostic,treatmentandcareinformationtothepersonmakingthecomplaint
on my behalf.
4. Use copies of this signed authorization form to collect information from physicians and
facilities.
This form authorizes the release of records, including medical information or otherwise,
concerning:
Print Full Name of Patient Date of Birth (day/month/year) AB Health Care #
IunderstandwhytheCPSAhasaskedformyconsenttosharemyinformation,andIamawareof
therisksorbenetsofconsenting,orrefusingtoconsent.Ialsounderstandmyconsentisvalidfor
atwo-yearperiodfromthedatesigned,andthatIcanrevokethisconsentinwritingatanytime.
Print Full Name of Patient or Legal Representative*
Signature of Patient or Legal Representative* Date signed (day/month/year)
Print Full Name of Witness
Signature of Witness Date signed (day/month/year)
*If you are the legal representative of the patient, please provide proof of guardianship, or if the
patient is deceased, a copy of the will naming you as Executor/Executrix.
File Number: ________________________ (CPSA Use Only)
Consent to Release Information
Complaints/Authorization for Release
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Consent to Release Information (College of Physicians & Surgeons of Alberta)

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Completed 4 May 2021

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