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Third Party Consent

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Third Party Consent

If a review request was made to the Patient Care Quality Review Boards on behalf of another person, this form must be completed and submitted by the individual who received the care or service involved in the care quality complaint or a person authorized under the common law or legislation to make health care decisions in respect of that individual.

If you are making a review request on behalf of another person, this form must be completed and submitted by the individual who received the care or service involved in the care quality complaint or a person authorized under the common law or legislation to make health care decisions in respect of that individual. By law, the review boards cannot collect, use, retain or disclose a person’s personal health information without a valid consent from that person or on his or her behalf. This consent becomes effective on the date this form is signed or authorized and remains in effect until the review is completed.

The Patient Care Quality Review Board office will contact the person named as giving consent by phone to verify their consent.

If you need assistance completing this form, please call 1 866 952-2448.

Consent

Name of person who is giving consentMissing or incorrect value

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I, the person named above, give my consent for the Patient Care Quality Review Board and the Secretariat acting on its behalf to collect the personal information of the person to whom the review request relates, from the person named below at the address named below.

Name of person submitting the review request on your behalfMissing or incorrect value

Daytime phone number Missing or incorrect value

AT

Address 1Missing or incorrect valueAddress of person submitting the request on your behalf

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Authorization

Select one of the following:By making this selection I confirm that I am the individual to whom the review request relates.By making this selection I confirm that I am authorized under the common law or legislation to make health care decisions in respect of the individual to whom the review request relates.

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And

I authorize the Patient Care Quality Review Board and the Secretariat acting on its behalf to disclose all information regarding this review request, including the personal information of the individual to whom the review request relates to the person submitting the review request on my behalf.

Date

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Keep a Copy for Your Records (optional)

To protect your personal information from third parties, we will not send you a copy of this form by email. If you want to keep a copy for your records, you can download a copy using the PDF button below.

HLTH 8108-2041 2021/08/17

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