Access to Personal Health Information (PHIA) Complaint Form

Your Information

Name

First Name Last Name

Mailing address

Street Address Address Line 2 City Postal Code

Please indicate the best way(s) to contact you if we need more information or have questions about your complaint:

Telephone

Telephone number(Required)

Email address(Required)

Are there any restrictions on contacting you?

For example, are there certain days of the week or times of day that you are available? (Note that our office hours are Monday to Friday, from 8:30 a.m. to 4:30 p.m.)

Your Request to Access to Your Personal Health Information

Name of the trustee* you are complaining about:

*Trustee means a health professional, health-care facility, public body, or health services agency

Address and phone number of the trustee, if known:

*Trustee means a health professional, health-care facility, public body, or health services agency

Your Complaint

In describing your complaint, please select one of the following:(Required)

No Response: I have not received an access decision from the trustee about my request for information.

Fees: I have been advised that a fee applies. I dispute the amount of the fee.

Complaint about the response: I am complaining about the access decision I received.

Other

Information(Required)

(describe how you requested information – verbally or in writing – and which personal health information you requested and/or attach a copy of your written request, if available)

My complaint is about:(Required)

The personal health information that was made available for examination, or the copies I was provided.

I was notified the information does not exist or cannot be found.

I was refused access to all or part of my personal health information under subsection 11(1). I was notified that the trustee disregarded my request under subsection 11.1(1).

Please provide any additional information you would like our office to know about your complaint:

Please describe any actions you have taken to resolve this matter with the trustee:

Representative Information

Complete this section only if you want another person to represent you. If you name a representative, we will communicate with this person about your complaint. I authorize the following person to act on my behalf and to receive any personal information about me, as necessary for the purposes of this complaint:

Telephone number(s)

Email address

Documents

Please include the following information when making your complaint to our office.

A copy of your PHIA access request to the trustee, if the request was made in writing and a copy of any written correspondence or access decision issued by the trustee in response to your PHIA access request. You will have other opportunities to provide documents.

Drop files here or

Max. file size: 50 MB, Max. files: 3.