Student Wellness - Release of Patient Information Form

* The patient is responsible for the $30.00 fee incurred for the transfer of an entire medical or counselling record. *

First Name:

Middle Name:

Last Name:

Health Card Number:

Student Number:

Phone:

Email:

Current Address (street number and name):

Apartment or suite:

Country

Province/State

City:

Postal/Zip Code:

Date of Birth:

Month

Day

Year

Records to be released:

Medical records (physician, psychiatrist, naturopathic doctor, nurse)

Specific records

Counsellor records (counsellor, social worker, psychologist, psychotherapist)

Specific records

Please send the above indicated patient records to:

Name of Health Care Provider:

Phone:

Fax:

Email:

Mailing Address (street number and name):

Apartment or suite:

Country

Province/State

City:

Postal/Zip Code:

Preferred method of transfer options:

Notes

The transfer of records is considered an uninsured service. The patient is responsible for the $30.00 fee incurred for the transfer of the medical and/or counselling record. By signing this form, the patient understands that with only a few exceptions, they have the right to view and request copies of information in their record. Exceptions include the reasonable possibility of serious harm to the patient or someone else, and confidential information in the record about a person other than the patient. If the patient believes that information in their record is not accurate, they may submit a written request to correct the record. If the Student Wellness Centre (SWC) does not agree with the correction request, the patient may file a notice of disagreement into their record. The patient acknowledges and understands that SWC is not responsible for the security of their records after they have been released.

*** The patient is responsible for the $30.00 fee incurred for the transfer of an entire medical or counselling record. ***

Date of Birth:

Records to be released:

Please send the above indicated patient records to:

Patient signature

* The patient is responsible for the $30.00 fee incurred for the transfer of an entire medical or counselling record. *