Health Records Request

Hospitals/Health Care Facilities:

How do I ask for my own health information?

ttt

If you are asking about health information on behalf of another person, click on How do I ask for someone else’s health information?

SUBMIT REQUEST USING ONLINE FORM:Request your own health information using online form

SUBMIT REQUEST BY EMAIL, MAIL, FAX OR IN PERSON:

Step 1: ACCESS THE FORM

Select the form below or you may pick up a paper form from any Health Records department in facilities operated by Fraser Health, Providence Health Care, Provincial Health Services Authority, or Vancouver Coastal Health.

Authorization for the Release of Health Records Form
PDF Document (89KB)

Step 2: FILL OUT & PRINT or PRINT & FILL OUT

You can fill out the form online and then print OR you can print the form and fill it out manually. Be as specific as possible in providing information. This helps us complete your request faster and ensures you receive all the documents you need. If you are uncertain about exact dates of care, please provide your best estimate. If you need help filling out the form, please see section below: "How do I fill out the Authorization for Release of Health Records form for my own health records?"

Step 3: SIGN & DATE

Once the form is printed, you must sign and date the form.

Step 4: SUBMIT THE FORM

Completed and signed request forms may be sent by EMAIL*, MAIL or FAX or dropped off IN PERSON to the Health Records department from which you are requesting records. Facility locations and contact information here.

* Using email to send your personal information to our health organization may cause risks to your privacy and security. By agreeing to use email, you accept these risks. Click here for more information. Although you may choose limited risk in submitting a request for health records using email, copies of health records will not be sent to personal email addresses to protect the privacy and security of the patient’s personal information. Secure File Transfer is offered to select organizations only.

How do I fill out the Authorization for Release of Health Records form for my own health records?

Part 1 – Patient / Resident Information:

If requesting your own health information, enter your legal last name and first name, also known as/alias (previous/preferred/nicknames), full mailing address, telephone number, date of birth and personal health number. Provide as much as possible as we will use this information to identify you and your health record correctly.

Part 2 – Records Requested:

Enter the name of the hospital(s) and/or other health care facility(ies) where your treatment was received. You may list as many as you wish. For example, ‘Vancouver General Hospital’ for records from one hospital/facility or ‘Vancouver General Hospital, Abbotsford UPCC, BC Cancer Vancouver’ for records from multiple hospital(s)/facility(ies).
Check off what reports you need: Visit summary, Emergency, Diagnostic Reports, Proof of Visit, Outpatient and/or Other. It is helpful to write the name of the clinic, program, or area where treatment was received. For example, Diabetes Clinic, Inpatient or Day Surgery.
Write the time period when the treatment was received at the hospital or health care facility. For example: ‘January 25-27, 2017’ for a specific date or when exact date is not known: ‘2017’ or ‘January 2017’ or ‘January-June 2017’ or ‘2016-2017’. If you are uncertain about exact dates of care, please provide your best estimate.

Part 3 – Person Receiving Records:

‘MYSELF’: Check off if you will be receiving your own health information. You do not need to add your mailing address and telephone number again if provided in Part 1.
‘NAME OF PERSON RECEIVING THE RECORDS’: Check off if want your health records to be sent to another person/organization. Provide the last and first names, company name (if applicable), full mailing address and telephone number for the other person/organization.
Indicate how you wish the records to be received by checking off ‘Mailed’ or ‘Picked Up’. Emailing copies of health records to personal email addresses is currently not offered to protect the privacy and security of the patient’s personal information. Secure File Transfer is offered to select organizations only.
‘MAILED’: Our response and copies of health information (if applicable) will be mailed to the address you have written on the form.
‘PICKED UP’: If you want to pick up our response and copies of health information (if applicable) from the Records Management department at the hospital or health care facility, you will be notified when the documents are ready to be picked up.

Part 4 – Patient Authorization (12 years of age or older):

This section must be signed and dated by capable adults and mature minors (12-18 years). It is your direction to us to release your health information to yourself or others.

Part 5 – Authorization on behalf of Patient (Please complete page 2 of form):

Not applicable. If you are the patient and Parts 1-3 are filled out and you have signed Part 4, the form is considered complete.

Click here to return to the top of the page.

Follow the steps below. If you are asking about health information on behalf of another person, click on How do I ask for someone else’s health information? [add link once created]

Step 1: ACCESS THE FORM

Select the form below or you may pick up a paper form from any Records Management department in facilities operated by Fraser Health, Providence Health Care, Provincial Health Services Authority, or Vancouver Coastal Health.

Authorization for the Release of Health Records Form
PDF Document (89kB)

Step 2: FILL OUT & PRINT or PRINT & FILL OUT

You can fill out the form online and then print OR you can print the form and fill it out manually. Be as specific as possible in providing information. This helps us complete your request faster and ensures you receive all the documents you need. If you are uncertain about exact dates of care, please provide your best estimate. If you need help filling out the form, please click below:

Step 3: SIGN & DATE

Once the form is printed, you must sign and date the form. Typed-in signatures and electronic signatures are not accepted.

Step 4: SUBMIT THE FORM

Completed and signed request forms may be sent by EMAIL*, MAIL or FAX or dropped off IN PERSON to the Records Management department from which you are requesting records. Facility locations and contact information here.

How do I ask for someone else's health information?

If you are asking about health information for yourself, click on How do I ask for my own health information?

SUBMIT REQUEST BY EMAIL, MAIL, FAX OR IN PERSON:

Step 1: ACCESS THE FORM

Authorization for the Release of Health Records Form
PDF Document (89KB)

Step 2: FILL OUT & PRINT or PRINT & FILL OUT

You can fill out the form online and then print OR you can print the form and fill it out manually. Be as specific as possible in providing information. This helps us complete your request faster and ensures you receive all the documents you need. If you are uncertain about exact dates of care, please provide your best estimate. If you need help filling out the form, please see the section below: "How do I fill out the Authorization for Release of Health Records form for someone else’s health records?"

Step 3: SIGN & DATE

Once the form is printed, you must sign the form.

Step 4: SUBMIT THE FORM AND OTHER DOCUMENTS AS APPLICABLE

Completed and signed request forms and, as applicable, copies of documents showing your authority to act on behalf of the patient, may be sent by EMAIL*, MAIL, FAX or dropped off IN PERSON to the Health Records department in the hospital/facility from which you are requesting records. Facility locations and contact information here.

How do I fill out the Authorization for Release of Health Records form for someone else’s health records?

Part 1 – Patient/Resident Information:

If you are requesting health information on behalf of someone else, for example, your child who is under 12 years old and cannot consent themselves, or your spouse for whom you have been given legal authority to make a request on his or her behalf because they are no longer able to consent themselves, or a deceased person for whom you have legal authority to act on their behalf, enter the legal last name, first name, also known as/alias (previous/preferred/nicknames),of the other person, their full mailing address, telephone number, date of birth and personal health number. Provide as much as possible as we will use this information to identify the other person and their health record correctly.

Part 2 – Records Requested:

Enter the name of the hospital(s) and/or other health care facility(ies) where treatment was received. You may list as many as you wish. For example, ‘Vancouver General Hospital’ for records from one hospital/facility or ‘Vancouver General Hospital, Abbotsford UPCC, BC Cancer Vancouver’ for records from multiple hospital(s)/facility(ies)
Check off what reports you need: Visit summary, Emergency, Diagnostic Reports, Proof of Visit, Outpatient and/or Other. It is helpful to write the name of the clinic, program or area where treatment was received. For example, Diabetes Clinic, Inpatient or Day Surgery.
Write the time period when the treatment was received at the hospital or health care facility. For example: ‘January 25-27, 2017’ for a specific date or when exact date is not known: ‘2017’ or ‘January 2017’ or ‘January-June 2017’ or ‘2016-2017’. If you are uncertain about exact dates of care, please provide your best estimate.

Part 3 – Person Receiving Records

‘MYSELF’: Do not check off as intended for patient’s requesting their own health records.
‘NAME OF PERSON RECEIVING THE RECORDS’: Check off and provide the last and first names, company name (if applicable), full mailing address and telephone number for the person/organization who will receive the records.
Indicate how you wish the records to be received by checking off ‘Mailed’ or ‘Picked Up’. Emailing copies of health records to personal email addresses is currently not offered to protect the privacy and security of the patient’s personal information. Secure File Transfer is offered to select organizations only.
‘MAILED’: Our response and copies of health information (if applicable) will be mailed to the address you have written on the form.
‘PICKED UP’: If you want to pick up our response and copies of health information (if applicable) from the Records Management department at the hospital or health care facility, you will be notified when the documents are ready to be picked up.

Part 4 – Patient Authorization (12 years of age or older):

Not applicable. This section is for patients to sign themselves. Go to Part 5.

Part 5 – Authorization on behalf of Patient (Please complete page 2 of form):

This section is completed when someone other than the patient is authorizing the release of the patient’s health information.
When requesting as a personal representative of the patient, you must check off ‘I have indicated my relationship to the patient on page 2 of this form’ and filled out one of the sections on Page 2 (see below).
If you are attaching documentation proving your legal authority to represent the patient, please check off ‘If applicable, I have attached documentation to show my status as legal representative or guardian’.
Most personal representatives will be asked to provide written proof of that representation except for parents who have lived with or regularly cared for the child patient under 12 years old and there is no legal order or agreement removing such guardianship and the relationship is already evident on the child’s health record. If needed, we will ask parents to confirm the relationship.
‘REASON FOR REQUEST’: You must provide a reason when you are requesting the health information of another person.
‘YOUR FULL NAME’: The person requesting release of information on behalf of the patient must print their legal first and last name.
‘YOUR SIGNATURE’ and ‘DATE SIGNED’: The person requesting release of information on behalf of the patient must sign and date the form after it is printed.

PAGE 2

When requesting health information as a personal representative of the patient, one of the three sections below must be filled out to indicate your legal authority to act on behalf of the patient. Check off the category in the application section that best describes your authority to act on behalf of the other person. We may contact you for more information if needed. Please attach a copy of documents proving your legal authority when applicable.

‘Authorization on behalf of an incapable adult’: This applies when an adult is not capable of providing consent themselves. Please refer to the form for examples of legal representation and, if none apply, you may write in an explanation of your legal representation.

‘Authorization on behalf of an incapable minor’: This applies to minors under 12 years of age (immature minors) or minors under 19 who are deemed incapable of authorizing for themselves (incapable minor). ‘Mature minors’ (12-18) who are deemed capable must sign Part 4 Patient Authorization.

‘Authorization on behalf of a deceased patient’: This applies to all requests for health information of a deceased patient. We must assess both the proof of legal representation as well as the reason for the request. If you have not done so already, ensure that the ‘Reason for Request’ is filled out in Part 5.

Click here to return to the top of the page.

You will receive a response within 30 business days from the date the request is received.

Correctional Health Services:

How do I ask for my own health information?

If you are asking about health information on behalf of another person, click on How do I ask for someone else’s health information?

SUBMIT REQUEST BY EMAIL, MAIL, OR FAX

Step 1: ACCESS THE FORM

Select the form below or call 604-524-7944 to request a paper form.

Correctional Health Services Request for Access to Health Information
PDF Document (148KB)

Step 2: FILL OUT & PRINT or PRINT & FILL OUT

You can fill out the form online and then print OR you can print the form and fill it out manually. Be as specific as possible in providing information. This helps us complete your request faster and ensures you receive all the documents you need. If you are uncertain about exact dates of care, please provide your best estimate. If you need help filling out the form, please see section below: “How do I fill out the Correctional Health Services Request for Access to Health Information form for my own health records”.

Step 3: SIGN & DATE

Once the form is printed, you must sign and date the form.

Step 4: SUBMIT THE FORM

Completed and signed request forms may be sent by:

EMAIL*: CHS.FOI.Requests@phsa.ca _{(only accepts requests for C}_{orrectional Health Services)}
FAX: 604-524-7913
MAIL: CHS Health Information Requests
c/o FPH HIM
70 Colony Farm Road
Coquitlam, BC V3C 5X9

* Using email to send your personal information to our health organization may cause risks to your privacy and security. By agreeing to use email, you accept these risks. Click here for more information. Although you may choose limited risk in submitting a request for health records using email, copies of health records will not be sent to personal email addresses to protect the privacy and security of the patient’s personal information. Secure File Transfer is offered to select organizations only.

How do I fill out the Correctional Health Services Request for Access to Health Information form for my own health records?

Site Selection:

Check off (√) the site(s) from which you are requesting health records.

Your Name, Address, and Contact Information:

Enter your legal last name, first name, and middle name (if applicable), as well as any other name(s) you are also known as/alias (previous/preferred/nicknames), full mailing address, daytime phone number, and alternate phone number.

Information Requested:

Describe the records you are requesting. Be as specific as possible. Attach a separate sheet if you need more space. If you are not sure about a detail, do the best you can to explain it. For example, you may describe a specific illness you experienced and/or were treated and/or specific test results.

Specify Time Frame for the Records:

Enter the dates ‘From’ and ‘To’ when care was received. If you are uncertain about exact dates of care, please provide your best estimate. For example: From 2017/01/25 To 2017/01/27 for specific dates or when exact date is not known: From 2015 To 2017 or From 2017/01/01 To 2017/01/31

Yourself?

Check off (√) the box next to ‘Yourself’.
Enter your Date of Birth, Correction Service Number (if applicable), and Other Unique Identifier, e.g., Personal Health Number (if applicable). Provide as much as possible as we will use this information to identify you and your health record correctly.

Another Person?

No action required as this is for requesting someone else’s health information

Your Signature and Date Signed:

This section must be signed and dated. It is your direction to us to release your health information to you.

Click here to return to the top of the page.

If you are asking about health information on behalf of another person, click on How do I ask for someone else’s health information? How do I ask for someone else's health information?

If you are asking about health information for yourself, click on How do I ask for my own health information?

Step 1: ACCESS THE FORM

Select the form below or call 604-524-7944 to request a paper form.

Correctional Health Services Request for Access to Health Information
PDF Document (148KB)

Step 2: FILL OUT & PRINT or PRINT & FILL OUT

You can fill out the form online and then print OR you can print the form and fill it out manually. Be as specific as possible in providing information. This helps us complete your request faster and ensures you receive all the documents you need. If you are uncertain about exact dates of care, please provide your best estimate. If you need help filling out the form, please see section below: “How do I fill out the Correctional Health Services Request for Access to Health Information form for someone else’s health records”.

Step 3: SIGN & DATE

Once the form is printed, you, the requestor, must sign and date the form.

Step 4: SUBMIT THE FORM

Completed and signed request forms may be sent by:

EMAIL*: CHS.FOI.Requests@phsa.ca _{(only accepts requests for}_{Correctional Health Services)}
FAX: 604-524-7913
MAIL: CHS Health Information Requests
c/o FPH HIM
70 Colony Farm Road
Coquitlam, BC V3C 5X9

How do I fill out the Correctional Health Services Request for Access to Health Information form for someone else’s health records?

Site Selection:

Check off (√) the site(s) from which you are requesting health records.

Your Name, Address, and Contact Information:

Enter your legal last name, first name, and middle name (if applicable), as well as any other name(s) you are also known as/alias (previous/preferred/nicknames), full mailing address, daytime phone number, and alternate phone number.

Information Requested:

Describe the records you are requesting on the other person and the reason for your request. Be as specific as possible. Attach a separate sheet if you need more space. If you are not sure about a detail, do the best you can to explain it. For example, you may describe a specific illness the other person experienced and/or was treated and/or specific test results.

Specify Time Frame for the Records:

Enter the dates ‘From’ and ‘To’ when care was received. If you are uncertain about exact dates of care, please provide your best estimate. For example: From 2017/01/25 To 2017/01/27 for specific dates or when exact date is not known: From 2015 To 2017 or From 2017/01/01 To 2017/01/31.

Yourself?

No action required as this is for requesting your own health information

Another Person?

Check off (√) the box next to ‘Another Person’.
Enter the other person’s legal full name as well as any other name(s) also known as/alias (previous/preferred/nicknames) and Date of Birth. Also enter Correction Service Number and Personal Health Number if available.

Attach Document(s)

You must provide proof that you can act on behalf of the other person as a personal representative. Documentation indicating your legal authority must be attached. We may contact you for more information if needed. Below are examples for guidance:

A ‘capable’ adult is a person who can provide consent for themselves. Include a note signed and dated by the other person stating their name and that they are consenting to you (stating your name) receiving their health information from the specified facilities (must state facilities).
An ‘incapable’ adult is a person whom is not capable of providing consent themselves. Documents may include Committee, Litigation Guardian, Representative Agreement, Power of Attorney.
For ‘deceased’ persons, the expectation is that the requestor provide documents showing they are authorized to act on behalf of the deceased. This includes the deceased’s Will or, in absence of a Will, a Grant of Administration or other order of the court appointing you as the designate. In certain cases of claiming insurance where the above criteria is not met, the beneficiary may provide proof of their status, so that we may provide information directly to the insurance company.

Your Signature and Date Signed:

This section must be signed and dated by you (the requestor). It is your direction to release the health information of the other person to you.

Click here to return to the top of the page.

You will receive a response within 30 business days from the date the request is received.

Provincial Portal: Health Gateway

BC residents may electronically access parts of your medical information from across the province including lab results, diagnostic imaging reports, medication history, select clinical documents, proof of vaccinations, organ donor status, and visit history from your physician/provider/hospital via the Health Gateway. Click this link for more information on how to register and what you can access quickly and directly: Health Gateway.

Immunization Records

Click here for more information.