The patient client or his her authorized representative must complete this form before Alberta Healt 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section A, enter the Patient/Client Name, Date of Birth, and Personal Health Number. Ensure all details are accurate for proper identification.
3. Move to Section B and specify the health information you wish to disclose. Include the name of the AHS location and the relevant time period for records.
4. In Section C, provide details about the individual or organization receiving the health information. Fill in their Name, Email, Address, City/Town, Phone, Province, and Postal Code.
5. Section D requires you to state the purpose for disclosure. Clearly articulate your reason as this is mandatory.
6. If applicable, complete Section E by selecting your relationship to the patient/client and providing supporting documents if you're an authorized representative.
7. Finally, in Section G, authorize disclosure by signing and dating where indicated. Make sure to include your contact information.

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