The Release Of Information Form Template – Canada is offered in several formats, including PDF, Word, and Google Docs. Each version is both customizable and suitable for printing, ensuring that you can use it according to your preferences.
Release Of Information Form Template – Canada Editable – PrintableSample
1. Parties Involved 2. Purpose of Release 3. Information to be Released 4. Duration of Authorization 5. Right to Revoke 6. Risks of Disclosure 7. Confidentiality Assurance 8. Signatures and Consent
PDF
WORD
Examples
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
[Provider’s Name]
[Provider’s Organization]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
The purpose of this authorization is to allow the release of my medical information for the following reason(s): [Specify Purpose].
I authorize the release of the following information:
[Specify the exact information that is to be released, e.g., medical records, lab results, etc.].
This authorization will expire on [Expiration Date] unless I revoke it in writing before that date.
I understand that I have the right to revoke this authorization at any time by providing written notice to the healthcare provider.
I acknowledge that information used or disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws.
By signing below, I confirm that I have read and understand this Release of Information Form and authorize the release of the specified information.
[Patient’s Signature]
[Date]
[Patient’s Name]
[Patient’s Health Card Number]
[Patient’s Address]
[Patient’s Phone Number]
[Name of Organization/Individual Receiving Information]
[Address of Recipient]
[Phone Number of Recipient]
I authorize the release of the following information:
[Detailed Description of Information, e.g., treatment records, consultation notes, etc.].
The information will be used for the purpose of: [Specific Purpose, e.g., treatment, personal use, insurance claims, etc.].
I understand that I do not have to sign this authorization, and that my health care will not be affected if I do not sign it. However, if I do not sign, my information may not be released.
This authorization will remain in effect until [Specify Duration or Event].
I acknowledge that I have read and understand this authorization, and I voluntarily give my consent for the disclosure of the information specified above.
[Signature]
[Printed Name]
[Date]
Printable
