Fill - Free fillable Disclosure Of PHI Consent Form Bundle PDF form

CONSENTFORDISCLOSUREOFPERSONALHEALTHINFORMATION



Disclosure–istheexposureofpersonalhealthinformationtoaseparateentity, notadivision orbranch ofthetrusteeincustodyor controlofthat

information.Anexampleofdisclos ureincludesthepermittedreleaseofpatientinformat iontoathird‐partyby theSaskatchewanHealthAut hority 

(SHA).



Authorization:

I,_______________________________________________,herebyauthorizethe____________________________________________________

(Fullnameofindividual,guardian ,orlegalrepresentati ve)     (Program/Facility)



toreleasethefollowingspecifiedheal t hinformationto_________________________________________________________________________.

(Person/Company/Agencyauthori zed toreceivehealthinformation)

Relationshiptopatient(i fnotthepatient):_________________________________________________________



Authorizer’sTelephoneNum ber: Home(______)________‐_______________Cell(______)________‐_______________



WhoseInformationisBeingRequested?

FirstandLast Name(asappearsonhealthcard)

HealthServicesNumb er (provinceofissueincluded) DateofBirt h (dd‐mmm‐yyyy)



PersonalHealthInformationRequested(Ifpossible,pleaseprovid edatesand locationswhereservic esareprovided):

_______________________________________________________________________________________________________________________



AddressofPerson/Company/AgencyAuthor izedtoReceiveHealthInformation: 

Address:___________________________________________________________________Town/City:_________________________________ 



Province/State:___________________________Country:___________________________________PostalorZipCode:________________



TelephoneNumber:(_____)_______‐__________________FaxNumber:(_____)_______‐____________________



Youwillbecontactedwithin30day s ofthereceiptofrequest.Iftheinformationisavailableyouwillbechar gedaprocessingfeeinaccordanc ewith

healthinformationmanagementpolicy,ora$20.00feeforexaminingrecordswithanSHAr epresentati ve.(GST/ PSTexem p t)



_______________________________________________________



(PrintedNameofapplicant)



_______________________________________________________



(Signatureofapplicant)



_________________________________________

(Date)

 Receivecopiesoforiginals



 Pickup only



 Fax



 Mailtoad dr es sabove



 ExamineoriginalswithanSHArepresentative

(appointmentrequired)



PleaserefertotheAccessGuidelin es forappropriatefacilitymailingaddress .



Foradministrativeuseonly:

Receivedby:_________________________________________________ Datereceived:________________________________________

Verify:Government issuedidentificationPermissiontocontactbytelephonePermissiontoleavemessageatabovetelephonenumber

Feeswaived:_______________________________ Approvedby:__________________________________________________________



SHA10/2019

InternalReferenceMRN

HOWTOCOMPLETEANDSUBMITACONSENTFOR

DISCLOSUREOFPERSONALHEALTHINFORMATONFORM



AuthorizationfortheRelease/DisclosureofInformation



 Enteryourfirstandlastname(asthepatient,guardia norlegal representative).

 Specifythespecificprogramorfacilityyouareauthorizingtoreleasetheinformation.

 Specifytheperson,companyoragencyyouareauthorizingtoreceivethehealthinformation.

 Enterthetelephonenumberatwhichyou(t

heauthorizer)maybecontactedduringbusinesshours.



WhoseInformationisBeingRequested?



 Enterthelastnameandfirstnameofthepatient(asitappearsontheHealthCard).

 EntertheHealthServicesNumberanddateofbirthofthepatient.



PersonalHealthInformationRequested



Pleasebeasspecificaspossibleincompletingthispartoftheform.ThiswillassisttheSaskatchewanHealth

Authorityinrespondingtoyour requestaccurately,completelyandquickly.

‐ Listthepreciserecordsorinformationyouarerequesting(e.g.:recordsrelatingtoanoutpatientvisit).

‐ Providethenameofthefa

cilitythatprovidedthehealthservices(e.g.:SaskatoonCityHospital).

‐ Specifythetimeperiodwhenthepatientreceivedhealthservices(thiswillallowstafftoretrieverecords

relatingtothoseservices).

‐ Identifytheclinic,programorareathatprovidedtheservices(e.g.:Emergency;Immunization;Social

WorkServices).



Addres

sofPerson/Company/AgencyAuthorizedtoReceiveHealthInformation



 Indicatethecompletemailingaddressandcontactinformationoftheperson,companyoragencyyou

wishtoreceivetheinformation.

 Indicatehowthehealthinformationshouldbedeliveredorpickedup.

 Signanddateyourrequest.



Authorization



Whenyoumakearequestforhealthinformation,youwillbeaskedtoprovideproofofyouridentitybeforethe

recordsareprovidedtoyou.



IfyouareaLegalGuardianorMedicalDecisionMaker,youwillbeaskedtoprovideevidenceofyourauthority

toexercisethatpower(e.g.:guardianshiporder;proxy;med

icaldecision‐makingdocumenta tion;excerptsfrom

awillnamingyouasexecutorandthedateandsignatureofthewill).



Payment



Allrequestsforhealthinformationaresubjecttoaprocessingfeeinaccordancewithhealthinformation

managementpolicy,ora$20.00feeforexaminingrecordswithanSHArepresentative.(GST/PSTexempt)



SubmissionofRequest



Submityourrequestbydeliveringinperson,mailingorfaxingtothefacilityyouaremakingtherequestto.In

ordertoassistyou,afacilitiescontactlistisprovidedbelow.Pleasecontactthelocationwhereyoureceived

healthservices.Ifyourrequestinvolvesmorethanonelocation,youwillonlybesubje

cttoasingleprocessing

fee.

ACUTECAREFACILITIES



Pleaselabelenvelope“Attn:HealthRecords/ReleaseofInformation”



ArcolaHealthCentre

607PrairieAvenue,Box419

Arcola,SKS0C0G0

Phone:306‐455‐2771



AssiniboiaUnionHospital

501‐6thAvenue,Box1120

Assiniboia,SKS0H0B0

Phone:306‐642‐9414



BiggarandDistrictHealthCentre

501‐1stAvenueWest,Box130

Biggar,SKS0K0M0

Phone:306‐948‐3323,ext.2725



BroadviewUnionHospital

901NinaStreet

Broadview,SKS0G0K0

Phone:306‐696‐5500



CanoraHospital

1219MainStreet,Box749

Canora,SKS0A0L0

Phone:306‐563‐1268



DavidsonHealthCentre

900GovernmentRoad,Box758

Davidson,SKS0G1A0

Phone:306‐567‐2801



Esterhazy‐St.Anthony'sHospital

216AnconaStreet,Box280

Esterhazy,SKS0A0X0

Phone:306‐745‐3973



Estevan‐St.Joseph'sHospital

1176NicholsonRoad

Estevan,SKS4A0H3

Phone:306‐637‐2452



FortQu'Appelle‐AllNations'Healing

Hospital

450‐8thStreet,Box300

FortQu'Appelle,SKS0G1S0

Phone:306‐332‐5611



Gravelbourg‐St.Joseph'sHospital

Box810

Gravelbourg,SKS0H1X0

Phone:306‐648‐3185



HerbertandDistrictIntegratedHealth

Facility

405HerbertAvenue

Herbert,SKS0H2A0

Phone:306‐784‐2466,ext.1

HudsonBayHealthCareFacility

614PrinceStreet,Box940

HudsonBay,SKS0E0Y0

Phone:306‐865‐5600



HumboldtDistrictHealthComplex

515‐14thAvenue,Box10

Humboldt,SKS0K2A0

Phone:306‐682‐8195



IleaLaCrosse‐St.Joseph'sHospital

andHealthCentre

Box630

IleaLaCrosse,SKS0M1C0

Phone:306‐833‐2016



IndianHeadUnionHospital

300HospitalStreet,Box340

IndianHead,SKS0G2K0

Phone:306‐695‐4000



KamsackHospitalandNursingHome

341StewartStreet,Box429

Kamsack,SKS0A1S0

P:306‐542‐1963



KelvingtonandAreaHospital

701‐6thAvenueWest,Box70

Kelvington,SKS0A1W0

Phone:306‐327‐5505



KerrobertandDistrictHealthCentre

115ManitobaAvenue,Box320

Kerrobert,SKS0L1R0

Phone:306‐834‐2646,ext.2800



KindersleyandDistrictHealthCentre

1003‐1stStreetWest

Kindersley,SKS0L1S2

Phone:306‐463‐1000,ext.2517



KiplingIntegratedHealthCentre

906IndustrialDrive,Box420

Kipling,SKS0G2S0

Phone:306‐736‐5501



LaLocheHealthCentreandHospital

BagService1

LaLoche,SKS0M1G0

Phone:306‐822‐3200



LaRongeHealthCentre

227BlacklundStreet,Box6000

LaRonge,SKS0J1L0

Phone:306‐425‐4828



LaniganUnionHospital

36DowningDriveEast,Box609

Lanigan,SKS0K2M0

Phone:306‐365‐1400



LeaderandDistrictIntegrated

HealthcareFacility

400‐1stStreetWest

Leader,SKS0N1H0

Phone:306‐628‐5513



LloydminsterHospital

3820‐43rdAvenue

Lloydminster,SKS9V1Y5

Phone:306‐820‐6000



MaidstoneHealthComplex

214‐5thAvenueEast,Box160

Maidstone,SKS0M1M0

Phone:306‐893‐2622



MapleCreekSouthwestIntegrated

HealthcareFacility

102‐5thAvenueWest

MapleCreek,SKS0N1N0

Phone:306‐662‐5802



MeadowLake‐NorthwestHealth

Facility

#1‐711CentreStreet

MeadowLake,SKS9X1E6

Phone:306‐236‐1500



MelfortHospital

510BroadwayAvenue,Box1480

Melfort,SKS0E1A0

Phone:306‐752‐8700



Melville‐St.Peter'sHospital

200HeritageDrive,Box1810

Melville,SKS0A2P0

Phone:306‐728‐9226



MooseJaw‐Dr.F.H.Wigmore

RegionalHospital

55DiefenbakerDrive

MooseJaw,SKS6J0C2

Phone:306‐694‐0289



Moosomin‐SoutheastIntegrated

CareCentre

601WrightRoad,Box1470

Moosomin,SKS0G3N0

Phone:306‐435‐6252



NipawinHospital

800‐6thStreetEast,Box389

Nipawin,SKS0E1E0

Phone:306‐862‐6100



NorthBattleford‐BattlefordsMental

HealthCentre

1092–107thStreet

NorthBattleford,SKS9A1Z1

Phone:306‐446‐6500



NorthBattleford‐BattlefordsUnion

Hospital

1092‐107thStreet

NorthBattleford,SKS9A1Z1

Phone:306

‐446‐6600



NorthBattleford‐Saskatchewan

Hospital

Box39

NorthBattleford,SKS9A2X8

Phone:306‐446‐6800



OutlookandDistrictHealthCentre

500SempleStreet,Box369

Outlook,SKS0L2N0

Phone:306‐867‐8676,ext.201



PorcupineCarraganaHospital

207ElmStreet,Box520

PorcupinePlain,SKS0E

1H0

Phone:306‐278‐2151



Preeceville&DistrictHealthCentre

712‐7thStreetNorthEast,Box469

Preeceville,SKS0A3B0

Phone:306‐547‐2102



PrinceAlbert‐VictoriaHospital

1200‐24thStreetWest

PrinceAlbert,SKS6V5T4

Phone:306‐765‐6073



RedversHealthCentre

18EichhorstStreet,Box

30

Redvers,SKS0C2H0

Phone:306‐452‐3553



Regina‐GeneralHospital

1440‐14thAvenue

Regina,SKS4P0W5

Phone:306‐766‐4899,Option2



Regina‐PasquaHospital

4101DewdneyAvenue

Regina,SKS4T1A5

Phone:306‐766‐2306

Regina‐WascanaRehabilitation

Centre

2180‐23rdAvenue

Regina,SKS4S

0A5

Phone:306‐766‐5657



RosetownandDistrictHealthCentre

409‐Highway4North,Box850

Rosetown,SKS0L2V0

Phone:306‐882‐2672,ext.2222



RosthernHospital

2016‐2ndStreet,Box309

Rosthern,SKS0K3R0

Phone:306‐232‐4811



Saskatoon‐RoyalUniversityandJim

PattisonChildren'sHospitals

RoyalUniversityHospital

103HospitalDrive

Saskatoon,SKS7N0W8

Phone:306‐655‐1722



Saskatoon‐St.Paul'sHospital

1702‐20thStreet

Saskatoon,SKS7M0Z9

Phone:306‐655‐5216



SaskatoonCityHospital

701QueenStreet

Saskatoon,SKS7K0M7

Phone:306‐655‐8351



ShaunavonHospital&CareCenter

660‐

4thStreetEast,Box789

Shaunavon,SKS0N2M0

Phone:306‐297‐1957



Shellbrook‐ParklandIntegrated

HealthCentre

#100Dr.J.L.SpencerDrive,Box70

Shellbrook,SKS0K3R0

Phone:306‐747‐2603



SwiftCurrent‐CypressRegional

Hospital

429‐4thAvenueNorthEast

SwiftCurrent,SKS9H2J9

Phone:306

‐778‐9480



TisdaleHospital

2010‐110thAvenueWest,Box1630

Tisdale,SKS0E1T0

Phone:306‐873‐6500

Turtleford‐RiversideHealthComplex

1stStreetSouth,Box10

Turtleford,SKS0M2Y0

Phone:306‐845‐2195



UnityandDistrictHealthCentre

AirportRoad,Box741

Unity,SKS0K4L0

Phone:

306‐228‐2666,ext.2965



WadenaHospital

433‐5thStreetNorthEast,Box10

Wadena,SKS0A4J0

Phone:306‐338‐9928



WatrousDistrictHealthComplex

702‐4thStreetEast,Box130

Watrous,SKS0K4T0

Phone:306‐946‐1200



WeyburnGeneralHospital

201‐1stAvenueNorthEast

Weyburn,

SKS4H0N1

Phone:306‐842‐8417



WolseleyMemorialIntegratedCare

Centre

801OuimetStreet,Box458

Wolseley,SKS0G5H0

Phone:306‐698‐4440



WynyardHospital

300‐10thStreetEast,Box670

Wynyard,SKS0A4T0

Phone:306‐554‐2586



YorktonRegionalHealthCentre

270BradbrookeDrive

Yorkton,

SKS3N2K6

Phone:306‐786‐0435

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