Required fields are marked with asterisks (*)

Consent for Release of Information

The patient or their authorized representative must complete this form before Muskoka Algonquin Healthcare (MAHC) will disclose a patient’s health information.

Please provide the first and last name of the person completing this form.

Authorization to Disclose Information

I, the above named person completing this form, hereby authorizes Muskoka Algonquin Healthcare to disclose the following personal health information.

Provide a description of the personal health information to be disclosed along with the dates of contact or hospitalization

I understand this personal health information is to be used by the recipient for the purposes of:

Name of person or agency receiving information

Address of person or agency receiving information

Preferred method of receiving this personal health information

Mail

E-mail

Fax

E-mail Address (please be advised that sending confidential records via e-mail has some risk as e-mail is not considered secure and can be intercepted. In choosing this method, you accept all risk)

Patient Information

Patient's First Name

Patient's Last Name

Patient's Mailing Address

Phone Number

Patient's Date of Birth

Indicate the hospital site that the patient received care at

Huntsville District Memorial Hospital

South Muskoka Memorial Hospital

Please upload any supporting documents you wish to attach to your request.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Signatures

Processing of this request may be subject to administration fees. Visit the MAHC Website to view the fee schedule.

Signature of Patient / Substitute Decision Maker / Legal Next of Kin

Clear

Date

First and Last Name of Witness

Signature of Witness:

Clear

Date