Get Consent To Disclose

Filling out the Consent to Disclose form is a crucial process for patients who wish to share their personal health information. This guide provides clear steps to help you complete the form accurately and efficiently, ensuring your information is handled properly.

Follow the steps to complete the Consent to Disclose form online.

1. Click ‘Get Form’ button to access the form and open it in the digital editor.
2. In the first section, print your name where indicated to specify the patient or substitute decision-maker (SDM) authorizing the disclosure.
3. Provide the relevant treatment dates in the designated fields, ensuring you write the dates in the correct format (dd/mm/yyyy).
4. Next, indicate the location of the treatment by selecting from the provided options: Credit Valley Hospital, Mississauga Hospital, or Queensway Health Centre.
5. Describe the specific personal health information you wish to disclose in the provided space.
6. Fill in the records from which the information will be disclosed, including the patient's name and date of birth (DOB) in the required format (dd/mm/yyyy).
7. Enter the health card number and phone number in the specified fields, ensuring accuracy.
8. Provide the full address of the patient, ensuring all sections, including city and postal code, are completed correctly.
9. Identify who the information is to be disclosed to, ensuring that you clearly print their name and address.
10. Confirm the purpose of the disclosure in the box provided to ensure compliance with privacy regulations.
11. Read the waiver section carefully, signing and dating the form to confirm your understanding and consent.
12. If applicable, fill in the contact information of the substitute decision-maker, including their relationship to the patient.
13. A witness must print their name and relationship, then sign and date the form as required.
14. If an interpreter was involved, ensure their details are filled out, including their name and signature.
15. Once all sections are completed, save your changes. You may also choose to download, print, or share the completed form as needed.

Complete your Consent to Disclose form online today to ensure your health information is shared securely.