ACCESS TO PERSONAL INFORMATION Upon Request We Will Give

ACCESS TO PERSONAL INFORMATION Upon Request We Will Give

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ACCESS TO PERSONAL INFORMATION
Upon request, we will give a patient (or the patient’s legally
authorized representative) access to his or her personal information
from the records we have in our custody or that are under our control.
Our privacy officer, ________________________________, will also
explain how we collect and use personal information, and to whom it
has been disclosed.
Within 30 business days of receiving your completed “Request for
Access to Personal Information” form (attached), we will provide you
with a copy of the information, let you review the original records if
we cannot reasonably provide copies to you, or give reasons for not
providing access. We may extend the time for responding to your
request in certain circumstances. We may also be permitted or required
by law to refuse to give you access to some information in your
records.
If we refuse access, our privacy officer will explain the reasons for
this. If you disagree with our refusal, we will try to resolve the
matter with you. If we cannot resolve the matter to your satisfaction,
you may ask the College of Physicians and Surgeons of BC to try to
resolve it. If you are still not satisfied, you may refer the matter
to the Office of the Information and Privacy Commissioner for BC.
BC’s Personal Information Protection Act allows us to charge you a
minimal fee for access to your personal information. If we wish to
charge a fee, we will provide you with a written estimate before we
provide the service. We may require you to pay a deposit for all or
part of the fee before we provide the service.
To request access to your personal information or information about a
person you are legally authorized to represent, please complete the
attached “Request for Access to Personal Information” form. If you
need assistance, our privacy officer will help you complete the form.
REQUEST FOR ACCESS TO PERSONAL INFORMATION
The information on this form will be used to respond to your request
for your personal information or the personal information of someone
whom you are legally entitled to represent.
Whose information do you want access to?
 My own personal information
 Another person’s personal information
Please complete the “Patient Information” and “Authorized
Representative’s Contact Information” sections below, and attach proof
that you can legally act on behalf of that individual.
Patient information
Mr / Mrs / Ms (please circle) Street address: _______________________
Last name: ________________________ City/town: _________________ Prov.
____
First name: ________________________ Postal code: ________
Fax_____________
Personal health number: _____________ Tel: (home) _________ (bus)
____________
Date of birth (dd/mm/yy): _____________ Email address:
_______________________
Please describe, in as much detail as possible, the information you
want to access. Indicate if you also want access to records about the
disclosure of your information, or information of the person you are
representing. Be sure to give previous names, if any.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please indicate if you wish to:
 Receive a photocopy of the record.
Please note that a base fee of $_______ per page applies for each page
copied. For convenience, you may enclose this fee with your request.
You will be provided with an estimate of any additional costs.
 View the original record, without receiving a copy.
Please ask for an estimate of the fee you will be charged for:
 Review of the original by the physician and / or
 Supervision by physician or designated staff person for your review
A deposit of 50% of the fee may be required.
__________________________________ ___________________________________
Patient Signature Date (dd/mm/yy)
(Authorized representatives – see following page)
Access by authorized representative
I am a legally authorized representative of the patient named above
and have attached proof of that representation. I hereby request
access to the patient’s personal records on his or her behalf.
Authorized representative’s contact information
Mr / Mrs / Ms (please circle) Street address: _______________________
Last name: ________________________ City/town: _________________ Prov.
_____
First name: ________________________ Postal code: ________
_________________
Telephone (home): __________________ Telephone (business)
__________________
Fax: _____________________________ Email address:
_______________________
__________________________________ ___________________________________
Authorized Representative's Signature Date (dd/mm/yy)