Adopted Person’s And Descendant Of Adopted Person’s Guide

Adopted Person’s and Descendant of Adopted Person’s Guide
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to Completing an Application
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for a Severe Medical Search
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Important: Please read this guide thoroughly before starting the
application process. Applications that are not complete or correct
will be returned and the processing of the application will be
delayed.
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General Information
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The purpose of a Severe Medical Search requested by an adopted person
or their descendant is to locate and contact a birth family member in
order to obtain or share medical information that will significantly
increase the likelihood of diagnosing or treating a severe mental or
physical illness. The information obtained as the result of a Severe
Medical Search may benefit the adopted person, the descendant of an
adopted person or a birth family member.
The Custodian of Adoption Information may conduct a Severe Medical
Search only in regard to an adoption that was registered in Ontario.
Who should use this form?
This form can be used by an adopted person, a descendant of an adopted
person (such as a child or grandchild), or by a person entitled to
apply on behalf of an adopted person or in regard to a deceased
adopted person.
Do not use this form if you are a member of the adopted person’s birth
family. Birth family members must use the Birth Family Member’s
Application to Request a Severe Medical Search.
The following people can use this form to apply to request
consideration for a Severe Medical Search:
*
adopted persons who have reached the age of 18;
*
an adopted person who is under 18 years of age with the consent of
his or her adoptive parent or legal guardian;
*
an adoptive parent or a person with legal custody of an adopted
person under 18 years of age;
*
the son, daughter, or any other descendant of an adopted person;
*
a person who is legally authorized to act on behalf of an adopted
person;
*
if an adopted person suffered from a severe mental and/or physical
illness and has died, the following persons can apply in regard to
the deceased adopted person:
i.
the spouse of the deceased adopted person;
ii.
the executor of the deceased adopted person’s estate;
iii.
a member of the College of Physicians and Surgeons of Ontario;
iv.
a member of the College of Psychologists of Ontario;
v.
a member of the College of Nurses of Ontario who holds a
certificate of registration in the extended class;
vi.
a person who is legally authorized to practice medicine or
psychology in a jurisdiction outside of Ontario.
Eligibility for a Severe Medical Search
The information you provide on the application form will be used to
determine if you are eligible for a Severe Medical Search. The
eligibility requirements of a Severe Medical Search are defined under
Section 16 of O.Reg. 464/07 made under the Child and Family Services
Act. Severe Medical Search requests that do not meet the eligibility
criteria will not be granted.
A Severe Medical Search for a birth family member will be conducted if
it is determined that an adopted person or the descendant of an
adopted person suffers from a severe physical and/or mental illness
and would derive a direct medical benefit in the event that his or her
birth family member is located and contacted.
OR
There is a reason to believe that the adopted person’s birth family
member will derive a direct medical benefit as a result of receiving
health information.
Direct medical benefit means a significant increase in the likelihood
of diagnosing or treating a severe mental or physical illness. Severe
physical or mental illnesses include those illnesses which are
life-threatening or will lead to permanent or irreversible damage,
impacting daily life. Verification of the nature, severity and urgency
of the situation must be provided by an appropriate, regulated health
care professional in Section D of the application form.
Completing the Application Form
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The application form has six sections. Please fill out all of the
information requested to the best of your ability by printing clearly
in blue or black ink. Some sections of the application form will not
apply to you and should be left blank.
Part D of the application form must be filled out by a physician or an
appropriate, regulated health care professional.
Part A: Applicant Information
Applicant Name
Please print your current, legal surname (your last name), your first
name and any middle names you may have in the section provided.
Applicant Gender
Check the box on the form to indicate whether you are male or female.
Date of Birth
Enter your date of birth in the space provided. Adopted persons must
be 18 years of age to apply without the consent of your adoptive
parent or legal guardian. If you are an adopted person under 18 years
old, your adoptive parent or legal guardian must provide written
consent by completing Part E of the application form.
Mailing Address
Enter your mailing address in the space provided. A mailing address is
necessary so we can mail you the results of your Severe Medical Search
application. This address will be used for all correspondence relating
to your application.
Daytime Telephone Number
Enter a daytime telephone number where you can be contacted during
regular business hours. Check the box to indicate whether a message
can be left for you at this number.
If it is not possible to leave a message at the daytime number you
have listed, or if there is another telephone number where you may be
reached (such as a cell phone number), enter that telephone number on
the form. If you do not have an alternate telephone number, leave that
space blank.
Additional Information about the Applicant
You must check the box on the form to indicate if you are:
*
an adopted person who has reached the age of 18;
*
an adopted person who is under 18 years of age with the consent of
your adoptive parent or legal guardian;
*
an adoptive parent or a person with legal custody of an adopted
person under 18 years of age;
*
the descendant of an adopted person. If you choose this option,
you must indicate your relationship to the adopted person in the
space provided. (e.g. son, daughter, grandson, etc.)
*
applying in on behalf of an adopted person as someone with the
legal authority to act on the adopted person’s behalf;
*
applying in regard to a deceased adopted person. If you choose
this option, you must check the appropriate box to indicate your
relationship to the deceased.
Purpose of the Severe Medical Search
A Severe Medical Search may be carried out in order to obtain or share
medical information. You must indicate the purpose of your search by
checking the appropriate box. You may check only one box.
Part B: Information About the Adopted Person AFTER Adoption
In order to process your application the following information about
the adopted person after their adoption is required:
*
Name of Adopted Person - Enter the adopted person’s legal surname
(last name), first name, and middle name(s) at the time of their
birth.
*
Sex – Check the box to indicate whether the adopted person is male
or female
*
Date of Birth – Enter the date of birth of the adopted person.
Please fill in the remaining information in this section to the best
of your ability. Additional information requested in this section of
the application may help speed the application process, but is not
required.
Part C: Information about the Adopted Person PRIOR to Adoption
If you are adopted and know your birth name, are aware of some of the
particulars of your birth parents or other details prior to your
adoption, you may provide those details in this section. Otherwise,
you may leave this section blank.
If you are the descendant of an adopted person, are applying on behalf
of an adopted person, or are applying in regard to a deceased adopted
person and know any of the particulars of the adopted person or his or
her birth parents prior to the adoption, please provide those details
in this section. Otherwise, you may leave this section blank.
Part D: Health Care Professional Questionnaire
The information provided in the Health Care Professional Questionnaire
will be used to determine your entitlement to a Severe Medical Search
under Section 16 of O.Reg. 464/07 made under the Child and Family
Services Act.
Important
The Health Care Professional Questionnaire must be submitted with your
Severe Medical Search Application. Applications that do not include a
completed Health Professional Questionnaire will be returned to the
applicant.
Patient Name
This section must be completed by the applicant.
If you are an adopted person or the descendant of an adopted person,
please print your current, legal name in the section provided.
If you are applying on behalf of an adopted person or in regard to a
deceased adopted person, you must print the current, legal name of the
adopted person in the section provided
Patient Consent to Disclose Health Information
In order for your health care professional to fill out the Health Care
Professional Questionnaire the Patient Consent section must be
completed. Please fill in the requested information including the name
of the health care professional who will be completing the
questionnaire. You must sign and date the consent statement.
Health Care Professional’s Information
The remainder of the Health Care Professional Questionnaire must be
completed and signed by an appropriate regulated health care
professional.
The health care professional must provide his or her full legal name
in the space provided and indicate his or her professional designation
by checking the appropriate box. If the health care professional is a
member of a professional association or college that is not listed on
the application form, he or she may check the box titled “other” and
must provide further details in the space provided.
The health care professional must also enter a business mailing
address and a daytime telephone number where they can be reached
during regular business hours.
Questions Regarding the Patient’s Health Condition
The information provided in response to these questions will be used
to determine if an applicant meets the eligibility requirements for a
Severe Medical Search. The health care professional must answer each
question by checking the appropriate box. If the answer to a question
is “yes” further details must be included in the space provided. If
additional space is required additional pages may be added.
The health care professional must sign and date the questionnaire and
return it to the applicant. As confirmation that he or she is a
regulated health care professional, a business card or letterhead must
be affixed to the questionnaire as indicated. Alternatively, he or she
may stamp or seal the questionnaire in the box indicated on the form.
Please note that the Custodian of Adoption Information may contact the
health care professional who completes the Health Care Professional
Questionnaire.
Part E: Consent of Adoptive Parent/Legal Guardian for Minor Adopted
Person
If you are an adopted person and you have not reached 18 years of age,
your adoptive parent or legal guardian must give his or her consent by
completing the consent form in Part E of the application. This form
must be signed by your adoptive parent or legal guardian.
Please note that the Custodian of Adoption Information may contact the
adoptive parent or legal guardian who signs the consent form.
Part F: Signed Statement by the Applicant
The applicant must sign and date the application as indicated in Part
F in order for it to be processed.
Mailing Instructions
Mail your completed Severe Medical Search Application including the
Health Care Professional Questionnaire to:
Custodian of Adoption Information
P.O. Box 654
77 Wellesley St. West
Toronto ON M7A 1N3
Applications that do not include a signed, completed Health Care
Professional Questionnaire will be returned to the applicant.
If you have any questions please contact:
ServiceOntario
Toll-free: 1 800 461-2156 or
Toronto: 416 325-8305
3090E Guide (2008/06) Page 0 of 4 7730-3090