Fillable MySaskHealthRecord REQUEST FOR ACCESS TO CHILDS MYSASKHEALTHRECORD I,

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MySaskHealthRecord REQUEST FOR ACCESS TO CHILDS MYSASKHEALTHRECORD I,

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MySaskHealthRecord
REQUEST FOR ACCESS TO CHILD’S MYSASKHEALTHRECORD
May 2021
I, the undersigned, understand that MySaskHealthRecord is a secure website enabling Saskatchewan
citizens to quickly and easily access their personal health information. A person who is legally responsible for
the care and custody of a child under the age of 14 may request access to the child’s MySaskHealthRecord.
eHealth must verify I am legally responsible for the care and custody of the child prior to granting access to
personal health information. Unless otherwise ordered by a court, if the parents of a child have never
cohabited after the birth of the child, or if the parents of a child have entered into an agreement related to
custody of the child, then pursuant to The Children’s Law Act, 1997, the parents of a child are presumed to
be joint legal custodians of the child with equal rights, powers and duties. If I am not the parent of the child or
if the child is the subject of a custody arrangement, I may be required to submit additional documentation to
show that I am authorized to request access to the child’s personal health information.
Personal health information on this form is collected under the authority of The Health Information Protection
Act (HIPA). This information will only be used by eHealth to ensure accuracy, confirm identity, and
authenticate this request. Personal health information is protected from unauthorized use and disclosure in
accordance with HIPA, and may only be collected, used and disclosed as provided by HIPA.
Section 1: Information about the child
Printed Full Name
Health Services Number
Date of Birth (yyyy-mon-dd)
Address
City/Town
Province
Postal Code
Section 2: Information about the applicant parent/person legally responsible for the care and
custody of the child
Printed Full Name
Relationship to Child
Health Services Number
Date of Birth (yyyy-mon-dd)
Email Address
Phone Number (During Business Hours)
Address
City/Town
Province
Postal Code
Section 3: Information related to proof of parentage/guardianship and declaration
The definition of a person who is legally responsible for the care and custody of the minor may not extend to the biological
parents of a child in all circumstances. A court order or agreement between the biological parents can give custody to only one
of the biological parents. A child could also have other guardians who are not biological parents such as a child’s grandparent
or other relative or other individual who has been granted a guardianship order by the Court. eHealth therefore must take
reasonable steps to ensure the applicant is the legal guardian of the child and one of those steps is to request legal
documentation related to the legal custody of the child in question.
You are required to submit proof of parentage/guardianship.
For example, long-form birth certificate, adoption order, or guardianship order.
Are there any separation agreements, court orders or legal proceedings pertaining to
custody of, mobility of, or access to the child?
Yes
No
If yes, please include
documentation as
evidence or have the
other parent/guardian
complete Section 4 below
Is the child currently the subject of an adoption process or partially or fully in the care
of a provincial family services organization in Saskatchewan?
Yes
No
If yes, please include
documentation as
evidence
MySaskHealthRecord
REQUEST FOR ACCESS TO CHILD’S MYSASKHEALTHRECORD
May 2021
I declare the information in this application is true and complete to the best of my knowledge. By typing your full name
in this space, you confirm it acts as your electronic signature and will be treated as an intention to be bound no
different than if you signed with pen and ink.
Note: It would be an offence under The Health Information Protection Act to obtain another person’s personal health
information by falsely representing that you are entitled to the information. You could be liable on summary conviction
to a fine of not more than $50,000, to imprisonment for not more than one year or to both.
Signature of Applicant Parent/Legal Guardian of Child
Date Signed
OPTIONAL Section 4: Information about the other parent/other person legally responsible for
the care and custody of the child
Printed Full Name
Relationship to Child
Health Services Number
Date of Birth (yyyy-mon-dd)
Email Address
Phone Number (During Business Hours)
Address
City/Town
Province
Postal Code
I have a MySaskHealthRecord account and would like access to my child’s MySaskHealthRecord
I declare the information in this application is true and complete to the best of my knowledge. By typing your full name
in this space, you confirm it acts as your electronic signature and will be treated as an intention to be bound no
different than if you signed with pen and ink.
Note: It would be an offence under The Health Information Protection Act to obtain another person’s personal health
information by falsely representing that you are entitled to the information. You could be liable on summary conviction
to a fine of not more than $50,000, to imprisonment for not more than one year or to both.
Signature of Other Parent/Legal Guardian of Child
Date Signed
Please submit this completed form, proof of parentage/guardianship, and any other documents to:
Email: privacyandaccess@eHealthsask.ca
Mail: eHealth Privacy Service
2130 11th Avenue
Regina, SK S4P 0J5
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MySaskHealthRecord REQUEST FOR ACCESS TO CHILDS MYSASKHEALTHRECORD I,

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Completed 11 January 2022

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