Request to Access, Correct or Disclose Personal Health Information (PHI)

ORG.1411.PL.101.FORM.01, ORG.1411.PL.104.FORM.01 & ORG.1411.PL.502.FORM.01

Do not use this form if requesting information related to your visit to a laboratory or radiology department, including Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) scan, Contact: Privacy and Security at Shared Health or eChart Manitoba.

This form is available in alternate formats upon request. Please contact us by email or 1-800-742-6509.

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

Request to Access, Correct or Disclose PHI

"*" indicates required fields

Step 1 of 3

33%

I am requesting…*

access to personal health information (PHI)

the trustee to disclose personal health information (PHI) to a third party

a correction to personal health information (PHI)

This request is being made…*

For myself

On behalf of another individual

This form is to be used when requesting PHI about yourself or another individual you are permitted to exercise the rights of. You may be required to provide two pieces of identification prior to receiving the PHI requested.

A base fee of $15 may be applied. Additional costs may also apply (e.g. copies exceeding 10 pages, cost of a Universal Serial Bus (USB) or retrieval fees related to offsite storage). If additional costs apply, you will be advised of the estimate of fees and asked to accept the estimate prior to processing this request.

*Where Visa, Mastercard or Interac is not accepted, payment can be made by cash or cheque made payable to Southern Health-Santé Sud.

This form is to be used only when a trustee is required to disclose PHI for a purpose that requires consent from the individual or a person permitted to exercise the rights of an individual.

You will be contacted if an administrative fee applies.

This form is to be used when an individual (a patient receiving health services from a hospital, client receiving community health services or a resident in a personal care home) requests a correction to their own PHI; or when a person permitted to exercise the rights of an individual requests a correction to PHI about the individual.

PART 1 – FOR MYSELF

Name

First Middle Initial Last

Birthdate (dd-mm-yyyy)

DD dash MM dash YYYY

Primary Phone

Email Address

Do you have a Manitoba PHI Number (PHIN)?

Yes

Please enter your Manitoba PHI Number (PHIN)

9-digit number on the Manitoba Health Card

Other Provincial / Territorial Health Insurance Number

Your Address

Street Address Address Line 2 City Province Postal Code

PART 1 – ON BEHALF OF ANOTHER INDIVIDUAL

Requestor's Name (You)

First Middle Initial Last

Your relationship to the individual

any person with written authorization from the individual to act on the individual’s behalf;

a proxy appointed by the individual under The Health Care Directives Act;

a committee appointed for the individual under The Mental Health Act if the committee has the power to make healthcare decisions on the individual’s behalf;

a substitute decision-maker for personal care appointed for the individual under The Vulnerable Persons Living with a Mental Disability Act if the exercise of the right relates to the powers and duties of the substitute decision-maker;

the parent or guardian of an individual who is a minor, if the minor does not have the capacity to make health-care decisions;

the personal representative if the individual is deceased;

other relationship

(select the appropriate)

Additional relationships to the individual

the individual’s spouse, or common-law partner, with whom the individual is cohabitating

a son or daughter

a parent, if the individual is an adult

a brother or sister

a person with whom the individual is known to have a close personal relationship

a grandparent

a grandchild

an aunt or uncle

a nephew or niece

File(s) Upload

Drop files here or

Accepted file types: doc, docx, pdf, jpg, jpeg, gif, png, Max. file size: 5 MB, Max. files: 5.

provide a copy of the supporting documents that confirm your authority to act on behalf of the individual

Requester’s Primary Phone

Requester’s Email address

Requester’s Address

Street Address Address Line 2 City Province Postal Code

Individual’s Name

First Middle Initial Last

Individual’s Birthdate (dd-mm-yyyy)

DD dash MM dash YYYY

Individual’s Primary Phone

Manitoba PHI Number (PHIN)?

Yes

Individual’s Manitoba PHI Number (PHIN)

9-digit number on the Manitoba Health Card

Individual’s Other Provincial / Territorial Health Insurance Number

The individual’s address is

same as requester

different from requester

unknown

Individual’s address

Street Address Address Line 2 City Province Postal Code

PART 2 – HEALTH RECORDS

Health records may be kept at more than one site (clinic, hospital, program, etc.). Please provide information where the PHI is being requested.

Name of site

(for ex. Altona Hospital, Home Care, etc.)

Location

(city / town where services were provided)

Date of Visit

Specific PHI being requested

Specific PHI being disclosed

Specify to whom the PHI is to be disclosed.

Name of organization / individual

Primary Phone

Email address

Specific correction to PHI being requested

Notes

Requester’s e-signature

Name

This field is for validation purposes and should be left unchanged.