Case/Patient # (Internal Use):
Page 1 of 1
Form 32152a Rev:2021 03 09
Please Print, Sign and Return
Request to Access Personal Information
For Homewood Health Inc. Stay at Work or
Return to Work Services clinical record access
requests, complete and return this form to:
Records Management, CIM-DS
Clinical Information Management – Data Services,
Homewood Health
150 Delhi Street, Guelph, Ontario N1E 6K9
Tele: (800) 265-8310, ext. 43113, Fax: (800) 427-9295
Email: requestforrecords@homewoodhealth.com
For Homewood Health Centre in-patient or out-
patient clinical record access requests, complete and
return this form to:
Correspondence, CIM
Clinical Information Management
Homewood Health
150 Delhi Street, Guelph, Ontario N1E 6K9
Tele: (519) 824-1010, ext. 32511, Fax: (519) 767-3552
Toll Free: (800) 265-8310, ext. 32511
Email: him@homewoodhealth.com
Print Full Name of Client/Patient
Client/Patient’s Date of Birth
Client/Patient Current Address & Telephone Number:
*or Substitute Decision Maker as indicated below
Full Mailing Address (Unit Number, PO Box, Street Number, Street Name, City, Province, Postal Code)
Primary Telephone Number Secondary Telephone Number(s)
Substitute Decision Makers (SDM):
if you are requesting information on behalf of a Client/Patient including a minor child,
provide your current address and contact information above. The Client/Patient must be incapable of making decisions regarding
the disclosure of personal information. Documentation to support your authority in the role of SDM is required.
SDM
Name (If Applicable):
I hereby request access to personal information held by Homewood Health, as specified below:
Confirmation of Attendance Letter (dates of attendance)
Confirmation Summary Letter (dates of attendance and overall issue addressed stated in 1-2 words )
Copies of clinical record(s) -*Fees Apply ($30 first 20 pages, $0.25 per page thereafter)
Describe the information being requested including date range and indicate the applicable treatment and/or service,
if known:
If you wish to examine your personal information at a Homewood Health office please contact us to schedule an appointment
Email Transmission: I authorize the email transmission of my unencrypted personal information to the above
recipient. I understand the risk of accidental disclosure, and the possibility that the information may be deliberately
intercepted by people other than the intended recipient.
Email Disclosure: Yes No
Email Address:
Password:
(Internal Use)
Signature of Witness (required)
Signature of Client/Patient/SDM (required)
SDM Relationship If Other Than Client/Patient
Written requests for personal Information invoke the rights and requirements set out in the applicable governing legislation.
