Important Forms
These are the forms we use in our office. Please print it, complete it and send it to the appropriate location.
AUTHORIZATION FOR DISCLOSURE OF MEDICAL RECORDS #1
This form is used to authorize the release of your medical records to a 3rd party. All sections should be completed.
Section 1 – Patient Information
Section 2 – The location of the records. (who has the records)
Section 3 – Who they are to be released to.
Complete all other sections and sign.
AUTHORIZATION FOR DISCLOSURE OF MEDICAL RECORDS #2
This form is partially completed to authorize the release of your medical records to WCFHT. All sections should be completed.
Section 1 – Patient Information
Section 2 – The location of the records. Usually, your previous physician.
Complete all other sections and sign.
AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION
This form is used to authorize the release of your medical records (verbally) to a designated party. All sections should be completed.
Section 1 – Patient Information
Section 2 – The patient delegate.
Complete all other sections and sign.
Our Location
119 Langstaff Drive
Box 218
Carp, Ontario
K0A 1L0
Phone: 613.839.3271
Fax: 613.839.3273