Authorization for Release/Collection

of Personal Health Information

Based on the Personal Health Information Protection Act, 2004
Health Information Services
1235 Wilson Avenue, Toronto, ON M3M 0B2
(P) 416-242-1000 ext. 82300 (F) 416-242-1085
E-mail: roi@hrh.ca

Health Card # (optional): _______________________________

1674-255-227-MG Medical Record Number: _______________________________
H001446022

Patient Name: ____________________________________________________

Nghiem Doan Gia Date of Birth: __________________________
20/11/1986
LAST NAME FIRST NAME (DD/MM/YYYY)

Address: _______________________________________________________________________________________________
345 Driftwood ave Toronto Ontario m3n2p4
STREET ADDRESS CITY PROVINCE POSTAL CODE

Contact Phone Number: _________________________________

3655243626 E-mail: ___________________________________________
nghiemdoan1120@gmail.com

I, _______________________________________________________________,
Doan Gia Nghiem hereby authorize Humber River Hospital to
(NAME OF PATIENT/SUBSTITUTE DECISION MAKER (SDM))

✔ RELEASE personal health information to: ✔ COLLECT personal health information from (INTERNAL USE ONLY):

Name of Person, Agency and/or Institution: ___________________________________________________________________

Detective Constable Mafi #11127 at Divison 31 416-808-3104

Address: _______________________________________________________________________________________________
40 North Finch Drive Toronto Ontario M3N2P4
STREET ADDRESS CITY PROVINCE POSTAL CODE

Contact Phone Number: __________________________

416-808-3104 Fax Number or E-mail: _____________________________________
11127@tps.ca

If COLLECTING, please send requested information back to:

HRH Unit or Clinic: __________________________________ Contact Name: ______________________________________

Phone Number: _______________________________________ Fax Number: _____________________________________

Please indicate which personal health information (with specific admission/visit date(s)) you are authorizing
Humber River Hospital to release or collect, as noted above:
______________________________________________________________________________________________________
I would like to have the detective above to collect all my health informations, records, footages, photos, video, lab test results of me when I was
______________________________________________________________________________________________________
at Humber River Hospital starting March 28 2017 to May 13 2021 as shown from the records I got at the hospital myself this year in 2023.

This information will be used for the purpose(s) of (SELECT AS MANY THAT APPLY):
Further Medical Treatment Coordination of Services ■ Litigation Insurance Claim Estate Settlement
■ Other: ______________________________________________________________________________________________
Prior to signing, I understand:
- That this authorization must be signed by the patient or by the legally authorized representative in the case that the patient is
deceased/deemed incapable by a medical professional.
- That typed signatures are not accepted.
Form # 000843, version (04/2021)

- The private and confidential nature of this information and agree that it will be used only for the stated purpose(s).
- That this authorization is valid for a period of 90 days from the date of signature unless specified otherwise.
- That personal health information will only be disclosed up to the date of signature.
- That a new Authorization for Release/Collection of Personal Health Information form will need to be completed for any information requested
beyond this date.
- That I may withdraw my consent in writing at any time, but this directive will not be applied retroactively.
- That the witness must be a capable individual who is 16 years or older, a neutral third party who does not benefit from signing this legal
document, and someone who physically sees the patient, SDM or legal representative sign.
- That if I am unable to have a witness sign this document, I will include a scanned copy of photo ID with this consent form.
Doan Nghiem
Signature of Patient, SDM or Legal Representative: ________________________________ Date: _______________________
November 15 2023
(DD/MM/YYYY)
Relationship to Patient (ONLY IF PATIENT DECEASED/DEEMED INCAPABLE OF SIGNING): _____________________________________________

Signature of Witness: ________________________________ Print Name of Witness: _________________________________

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