Appendix D: Personal Health Information Protection Act Forms

• Author: Richard D. Schneider
• Pages: 622-629

622 ANNOTATED ONTARIO MENTAL HEALTH STATUTES

Consent and

Capacity

Board

Form P-1

Personal Health Informa-

tion

Protection Act

Application to the Board to Review a

Finding of Incapacity to Consent to the

Collection, Use or Disclosure of Personal

Health Information under Subsection

22(3) of the Act

Full Name of Applicant (please print)

I apply to the Board for a hearing to dete rmine whether or not I am capable,

(check appropriate box(es))

 to consent to the collection of personal he alth information;

 to consent to the use of personal health information;

 to consent to the disclosure of personal health information.

Note: An application may only be made if a health information custodian has made a relevant

determination of incapacity.

Provide the name, address, telephone and fax numb ers of the person who made the determination

of incapacity.

Name Address

Telephone No. (incl. area cod e) Fax No. (incl. area co de)

Are you currently an in-patient or resident at a he alth or residential facility?

 No

 Yes (if “Yes”, provide Name, Address and Telephone Number of facilit y)

Name of Facility Address

Telephone No. (incl. area cod e)

Your home address and telephone number or other way to contact you.

Home Address Telephone No. (incl. area cod e)

Name, address, telephone and fax number s of your lawyer or agent (if any).

Name of Lawyer/Agent Address

Telephone No. (incl. area cod e) Fax No. (incl. area co de)

(Disponible e n version français e)

4351-04 (2004/10) Form P-1 (Page 1 of 2) www.ccbord.on.ca © Queen’s Printer for Ontario, 2004