Get Consent To Disclose Personal Health Information Form - St. Joseph's ...

Filling out the Consent to Disclose Personal Health Information form is an essential step in sharing your personal health information. This guide provides clear, step-by-step instructions to help you complete the form online with confidence.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the form and open it in your browser or preferred document editor.
2. In the first section, print your name where indicated. This is necessary to identify who is providing consent.
3. Next, authorize St. Joseph’s Health Centre to disclose your personal health information by providing the full name of the individual or organization you are authorizing to receive this information.
4. Complete the address section with the full contact details of the authorized recipient, ensuring accuracy.
5. Fill in the telephone number and fax number of the authorized recipient, if applicable.
6. Identify what personal health information you wish to disclose by checking one of the boxes and describing the information, including treatment dates and types of reports.
7. If you are acting as a substitute decision maker, provide the name of the person for whom you are making the disclosure.
8. Complete the date of birth, health card number, address, and telephone number fields for the individual whose information is being shared.
9. Sign and date the form to confirm your consent.
10. Provide the name and signature of a witness.
11. Lastly, save your changes, and make sure to download, print, or share the completed form as required.

Complete your documents online today and ensure your health information is managed with care.