Third Party Consent

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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

Missing or incorrect value
555-555-5555 Missing or incorrect value
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.
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555-555-5555 Missing or incorrect value
AT
Missing or incorrect valueAddress of person submitting the request on your behalf
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Missing or incorrect valueFormat as A1A 1A1

Authorization

Select one of the following:
Remove File
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 Missing or incorrect value

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 2024/05/22
b117bf9f02dc38913d2b879309507398c2d5dc47
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