Important Forms

These are the forms that our office needs completed for disclosure of personal information.
Please print it, complete it and send it to the appropriate location.

F1-VERBAL 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.

<get the form F1 here>

F3-Authorization to Tranfers Medical Records FROM WCFHT
This form is used to authorize the release of your medical records from WCFHT to a 3rd party. All sections should be completed.
Section 1 – Patient Information
Section 3 – Who they are to be released to.
Complete all other sections and sign.

<get the form F3 here>

F4-Authoirzation to Transfer Medical Records TO WCHFT
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.

<get the form F4 here>

F5-Authorization for Disclosure of Medical Records
This form is used to authorize the release of your medical records to a designated 3rd party (such as an Insurance Company). All sections should be completed.
Section 1 - Patient Information
Section 3 - Records Released To
Complete all other sections and sign.

<get the form F5 here>

 

Our Location

119 Langstaff Drive
Box 218
Carp, Ontario
K0A 1L0
Phone: 613.839.3271
Fax: 613.839.3273