CONSENTFORDISCLOSUREOFPERSONALHEALTHINFORMATION
Disclosureistheexposureofpersonalhealthinformationtoaseparateentity, notadivision orbranch ofthetrusteeincustodyor controlofthat
information.Anexampleofdisclos ureincludesthepermittedreleaseofpatientinformat iontoathirdpartyby theSaskatchewanHealthAut hority
(SHA).
Authorization:
I,_______________________________________________,herebyauthorizethe____________________________________________________
(Fullnameofindividual,guardian ,orlegalrepresentati ve)  (Program/Facility)
toreleasethefollowingspecifiedheal t hinformationto_________________________________________________________________________.
(Person/Company/Agencyauthori zed toreceivehealthinformation)
Relationshiptopatient(i fnotthepatient):_________________________________________________________
Authorizer’sTelephoneNum ber: Home(______)________‐_______________Cell(______)________‐_______________
WhoseInformationisBeingRequested?
FirstandLast Name(asappearsonhealthcard)
HealthServicesNumb er (provinceofissueincluded) DateofBirt h (ddmmmyyyy)
PersonalHealthInformationRequested(Ifpossible,pleaseprovid edatesand locationswhereservic esareprovided):
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
AddressofPerson/Company/AgencyAuthor izedtoReceiveHealthInformation:
Address:___________________________________________________________________Town/City:_________________________________ 
Province/State:___________________________Country:___________________________________PostalorZipCode:________________
TelephoneNumber:(_____)_______‐__________________FaxNumber:(_____)_______‐____________________
Youwillbecontactedwithin30day s ofthereceiptofrequest.Iftheinformationisavailableyouwillbechar gedaprocessingfeeinaccordanc ewith
healthinformationmanagementpolicy,ora$20.00feeforexaminingrecordswithanSHAr epresentati ve.(GST/ PSTexem p t)
_
_______________________________________________________
_
(PrintedNameofapplicant)
_
_______________________________________________________
_
(Signatureofapplicant)
_
_________________________________________
(Date)
Receivecopiesoforiginals
Pickup only
Fax
Mailtoad dr es sabove
ExamineoriginalswithanSHArepresentative
(appointmentrequired)
PleaserefertotheAccessGuidelin es forappropriatefacilitymailingaddress .
Foradministrativeuseonly:
Receivedby:_________________________________________________ Datereceived:________________________________________
Verify:Government issuedidentificationPermissiontocontactbytelephonePermissiontoleavemessageatabovetelephonenumber
Feeswaived:_______________________________ Approvedby:__________________________________________________________
SHA10/2019
InternalReferenceMRN
HOWTOCOMPLETEANDSUBMITACONSENTFOR
DISCLOSUREOFPERSONALHEALTHINFORMATONFORM
AuthorizationfortheRelease/DisclosureofInformation
Enteryourfirstandlastname(asthepatient,guardia norlegal representative).
Specifythespecificprogramorfacilityyouareauthorizingtoreleasetheinformation.
Specifytheperson,companyoragencyyouareauthorizingtoreceivethehealthinformation.
Enterthetelephonenumberatwhichyou(t
heauthorizer)maybecontactedduringbusinesshours.
WhoseInformationisBeingRequested?
Enterthelastnameandfirstnameofthepatient(asitappearsontheHealthCard).
EntertheHealthServicesNumberanddateofbirthofthepatient.
PersonalHealthInformationRequested
Pleasebeasspecificaspossibleincompletingthispartoftheform.ThiswillassisttheSaskatchewanHealth
Authorityinrespondingtoyour requestaccurately,completelyandquickly.
Listthepreciserecordsorinformationyouarerequesting(e.g.:recordsrelatingtoanoutpatientvisit).
Providethenameofthefa
cilitythatprovidedthehealthservices(e.g.:SaskatoonCityHospital).
Specifythetimeperiodwhenthepatientreceivedhealthservices(thiswillallowstafftoretrieverecords
relatingtothoseservices).
Identifytheclinic,programorareathatprovidedtheservices(e.g.:Emergency;Immunization;Social
WorkServices).
Addres
sofPerson/Company/AgencyAuthorizedtoReceiveHealthInformation
Indicatethecompletemailingaddressandcontactinformationoftheperson,companyoragencyyou
wishtoreceivetheinformation.
Indicatehowthehealthinformationshouldbedeliveredorpickedup.
Signanddateyourrequest.
Authorization
Whenyoumakearequestforhealthinformation,youwillbeaskedtoprovideproofofyouridentitybeforethe
recordsareprovidedtoyou.
IfyouareaLegalGuardianorMedicalDecisionMaker,youwillbeaskedtoprovideevidenceofyourauthority
toexercisethatpower(e.g.:guardianshiporder;proxy;med
icaldecisionmakingdocumenta tion;excerptsfrom
awillnamingyouasexecutorandthedateandsignatureofthewill).
Payment
Allrequestsforhealthinformationaresubjecttoaprocessingfeeinaccordancewithhealthinformation
managementpolicy,ora$20.00feeforexaminingrecordswithanSHArepresentative.(GST/PSTexempt)
SubmissionofRequest
Submityourrequestbydeliveringinperson,mailingorfaxingtothefacilityyouaremakingtherequestto.In
ordertoassistyou,afacilitiescontactlistisprovidedbelow.Pleasecontactthelocationwhereyoureceived
healthservices.Ifyourrequestinvolvesmorethanonelocation,youwillonlybesubje
cttoasingleprocessing
fee.
ACUTECAREFACILITIES
Pleaselabelenvelope“Attn:HealthRecords/ReleaseofInformation”
ArcolaHealthCentre
607PrairieAvenue,Box419
Arcola,SKS0C0G0
Phone:3064552771
AssiniboiaUnionHospital
501‐6thAvenue,Box1120
Assiniboia,SKS0H0B0
Phone:3066429414
BiggarandDistrictHealthCentre
501‐1stAvenueWest,Box130
Biggar,SKS0K0M0
Phone:3069483323,ext.2725
BroadviewUnionHospital
901NinaStreet
Broadview,SKS0G0K0
Phone:3066965500
CanoraHospital
1219MainStreet,Box749
Canora,SKS0A0L0
Phone:3065631268
DavidsonHealthCentre
900GovernmentRoad,Box758
Davidson,SKS0G1A0
Phone:3065672801
Esterhazy‐St.Anthony'sHospital
216AnconaStreet,Box280
Esterhazy,SKS0A0X0
Phone:3067453973
Estevan‐St.Joseph'sHospital
1176NicholsonRoad
Estevan,SKS4A0H3
Phone:3066372452
FortQu'Appelle‐AllNations'Healing
Hospital
450‐8thStreet,Box300
FortQu'Appelle,SKS0G1S0
Phone:3063325611
Gravelbourg‐St.Joseph'sHospital
Box810
Gravelbourg,SKS0H1X0
Phone:3066483185
HerbertandDistrictIntegratedHealth
Facility
405HerbertAvenue
Herbert,SKS0H2A0
Phone:3067842466,ext.1
HudsonBayHealthCareFacility
614PrinceStreet,Box940
HudsonBay,SKS0E0Y0
Phone:3068655600
HumboldtDistrictHealthComplex
515‐14thAvenue,Box10
Humboldt,SKS0K2A0
Phone:3066828195
IleaLaCrosse‐St.Joseph'sHospital
andHealthCentre
Box630
IleaLaCrosse,SKS0M1C0
Phone:3068332016
IndianHeadUnionHospital
300HospitalStreet,Box340
IndianHead,SKS0G2K0
Phone:3066954000
KamsackHospitalandNursingHome
341StewartStreet,Box429
Kamsack,SKS0A1S0
P:3065421963
KelvingtonandAreaHospital
701‐6thAvenueWest,Box70
Kelvington,SKS0A1W0
Phone:3063275505
KerrobertandDistrictHealthCentre
115ManitobaAvenue,Box320
Kerrobert,SKS0L1R0
Phone:3068342646,ext.2800
KindersleyandDistrictHealthCentre
1003‐1stStreetWest
Kindersley,SKS0L1S2
Phone:3064631000,ext.2517
KiplingIntegratedHealthCentre
906IndustrialDrive,Box420
Kipling,SKS0G2S0
Phone:3067365501
LaLocheHealthCentreandHospital
BagService1
LaLoche,SKS0M1G0
Phone:3068223200
LaRongeHealthCentre
227BlacklundStreet,Box6000
LaRonge,SKS0J1L0
Phone:3064254828
LaniganUnionHospital
36DowningDriveEast,Box609
Lanigan,SKS0K2M0
Phone:3063651400
LeaderandDistrictIntegrated
HealthcareFacility
400‐1stStreetWest
Leader,SKS0N1H0
Phone:3066285513
LloydminsterHospital
3820‐43rdAvenue
Lloydminster,SKS9V1Y5
Phone:3068206000
MaidstoneHealthComplex
214‐5thAvenueEast,Box160
Maidstone,SKS0M1M0
Phone:3068932622
MapleCreekSouthwestIntegrated
HealthcareFacility
102‐5thAvenueWest
MapleCreek,SKS0N1N0
Phone:3066625802
MeadowLake‐NorthwestHealth
Facility
#1711CentreStreet
MeadowLake,SKS9X1E6
Phone:3062361500
MelfortHospital
510BroadwayAvenue,Box1480
Melfort,SKS0E1A0
Phone:3067528700
Melville‐St.Peter'sHospital
200HeritageDrive,Box1810
Melville,SKS0A2P0
Phone:3067289226
MooseJaw‐Dr.F.H.Wigmore
RegionalHospital
55DiefenbakerDrive
MooseJaw,SKS6J0C2
Phone:3066940289
Moosomin‐SoutheastIntegrated
CareCentre
601WrightRoad,Box1470
Moosomin,SKS0G3N0
Phone:3064356252
NipawinHospital
800‐6thStreetEast,Box389
Nipawin,SKS0E1E0
Phone:3068626100
NorthBattleford‐BattlefordsMental
HealthCentre
1092107thStreet
NorthBattleford,SKS9A1Z1
Phone:3064466500
NorthBattleford‐BattlefordsUnion
Hospital
1092‐107thStreet
NorthBattleford,SKS9A1Z1
Phone:306
4466600
NorthBattleford‐Saskatchewan
Hospital
Box39
NorthBattleford,SKS9A2X8
Phone:3064466800
OutlookandDistrictHealthCentre
500SempleStreet,Box369
Outlook,SKS0L2N0
Phone:3068678676,ext.201
PorcupineCarraganaHospital
207ElmStreet,Box520
PorcupinePlain,SKS0E
1H0
Phone:3062782151
Preeceville&DistrictHealthCentre
712‐7thStreetNorthEast,Box469
Preeceville,SKS0A3B0
Phone:3065472102
PrinceAlbert‐VictoriaHospital
1200‐24thStreetWest
PrinceAlbert,SKS6V5T4
Phone:3067656073
RedversHealthCentre
18EichhorstStreet,Box
30
Redvers,SKS0C2H0
Phone:3064523553
Regina‐GeneralHospital
1440‐14thAvenue
Regina,SKS4P0W5
Phone:3067664899,Option2
Regina‐PasquaHospital
4101DewdneyAvenue
Regina,SKS4T1A5
Phone:3067662306
Regina‐WascanaRehabilitation
Centre
2180‐23rdAvenue
Regina,SKS4S
0A5
Phone:3067665657
RosetownandDistrictHealthCentre
409‐Highway4North,Box850
Rosetown,SKS0L2V0
Phone:3068822672,ext.2222
RosthernHospital
2016‐2ndStreet,Box309
Rosthern,SKS0K3R0
Phone:3062324811
Saskatoon‐RoyalUniversityandJim
PattisonChildren'sHospitals
RoyalUniversityHospital
103HospitalDrive
Saskatoon,SKS7N0W8
Phone:3066551722
Saskatoon‐St.Paul'sHospital
1702‐20thStreet
Saskatoon,SKS7M0Z9
Phone:3066555216
SaskatoonCityHospital
701QueenStreet
Saskatoon,SKS7K0M7
Phone:3066558351
ShaunavonHospital&CareCenter
660‐
4thStreetEast,Box789
Shaunavon,SKS0N2M0
Phone:3062971957
Shellbrook‐ParklandIntegrated
HealthCentre
#100Dr.J.L.SpencerDrive,Box70
Shellbrook,SKS0K3R0
Phone:3067472603
SwiftCurrent‐CypressRegional
Hospital
429‐4thAvenueNorthEast
SwiftCurrent,SKS9H2J9
Phone:306
7789480
TisdaleHospital
2010‐110thAvenueWest,Box1630
Tisdale,SKS0E1T0
Phone:3068736500
Turtleford‐RiversideHealthComplex
1stStreetSouth,Box10
Turtleford,SKS0M2Y0
Phone:3068452195
UnityandDistrictHealthCentre
AirportRoad,Box741
Unity,SKS0K4L0
Phone:
3062282666,ext.2965
WadenaHospital
433‐5thStreetNorthEast,Box10
Wadena,SKS0A4J0
Phone:3063389928
WatrousDistrictHealthComplex
702‐4thStreetEast,Box130
Watrous,SKS0K4T0
Phone:3069461200
WeyburnGeneralHospital
201‐1stAvenueNorthEast
Weyburn,
SKS4H0N1
Phone:3068428417
WolseleyMemorialIntegratedCare
Centre
801OuimetStreet,Box458
Wolseley,SKS0G5H0
Phone:3066984440
WynyardHospital
300‐10thStreetEast,Box670
Wynyard,SKS0A4T0
Phone:3065542586
YorktonRegionalHealthCentre
270BradbrookeDrive
Yorkton,
SKS3N2K6
Phone:3067860435
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