Please fax or mail your completed request to each hospital facility you are requesting records from 2025

1. Begin by clicking ‘Get Form’ to open the document in our editor.
2. In Part 1, enter the patient's last name, first name, and any aliases. Fill in the mailing address, city, province, country, telephone number, date of birth, postal code, and personal health number.
3. Move to Part 2 to specify the records requested. Check the appropriate boxes for visit summaries, emergency visit information, outpatient records, or diagnostic reports. Include the dates of records requested; if unsure, provide your best estimate.
4. In Part 3, indicate who will receive the records by selecting either yourself or another person. Provide their name and contact details.
5. Part 4 requires patient authorization. The patient must sign and date this section to authorize release of records.
6. If applicable, complete Part 5 for authorization on behalf of a patient under 12 years old or unable to authorize themselves. Ensure all necessary documentation is attached.

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