Disclosure Authorization Consent Form
In today’s world, it is common for a spouse or partner to arrange appointments for their family members, or for a parent or guardian to assist with the health care needs of adult family members. However, it is not permissible for a spouse to act on their spouse’s behalf, or a parent/guardian on behalf of a patient that has aged out of pediatric consent, age 14 and over, unless authorized.
Pursuant to the Personal Health Information Act, 2004 (PHIPA), the form below is for the purpose of authorizing someone other than yourself to communicate with our staff with regard to your medical information (see page 2 for details). This form can be completed at your convenience and the original submitted at either the Erin or Rockwood clinic. Please note that you may be contacted to verify the authenticity of your consent if someone, other than yourself, delivers this form.
Alternatively, you may contact us by phone (Erin: 519-833-9396 or Rockwood: 519-856-4611) and ask that your verbal consent be documented in your chart. If you choose the phone-in option, staff will explain to you what your consent means and how it will be carried out.
If you have given us permission to share your health information with someone, i.e. family or friend, please know that this consent remains in your chart until you instruct us otherwise. If you would like to remove this permission, please speak with your doctor or reception staff.
