Appendix D: Personal Health Information Protection Act Forms

AuthorRichard D. Schneider
Consent and
Form P-1
Personal Health Informa-
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?
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) © Queen’s Printer for Ontario, 2004

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