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Request for access to personal information html

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<span style="position:absolute; left:150px; top:20px; font-family:sans-serif; font-size:14px;" ><b><u>REQUEST FOR ACCESS TO PERSONAL INFORMATION</u></b></span>

<span style="position:absolute; left:10px; top:40px; width:700px; font-family:sans-serif; font-size:14px;">The information on this form will be used to respond to your request for your personal information or the personal information of someone whom you are legally entitled to represent.<br><br>

<b>Whose information do you want access to?</b><br>

<input name="Personal" id="Personal" type="text" class="XBox box1" > &nbsp; &nbsp; &nbsp; &nbsp; My own personal information.<br>

<input name="Another" id="Another" type="text" class="XBox box1" > &nbsp; &nbsp; &nbsp; &nbsp; Another person&#8217;s personal information.<br>

</span>

<span style="position:absolute; left:40px; top:150px; width:680px; font-family:sans-serif; font-size:14px;">Please complete the &quot;Patient Information&quot; and &quot;Authorized Represetative&#8217;s Contact Information&quot; sections below, and attach proof that you can legally act on behalf of that individual.

</span>

<span style="position:absolute; left:10px; top:200px; width:700px; font-family:sans-serif; font-size:14px;"><b>Patient information</b><br>

<input name="Mr" id="Mr" type="text" class="XBox box2" > &nbsp; &nbsp; Mr. <input name="Mrs" id="Mrs" type="text" class="XBox box2" > &nbsp; &nbsp; Mrs. <input name="Miss" id="Miss" type="text" class="XBox box2" > &nbsp; &nbsp; Miss <input name="Ms" id="Ms" type="text" class="XBox box2" > &nbsp; &nbsp; Ms <br>

Last Name&#58; <input name="LastName" id="LastName" type="text"  style="width:250px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"  oscarDB=patient_nameL><br>

First Name&#58; <input name="FirstName" id="FirstName" type="text"  style="width:249px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"  oscarDB=patient_nameF><br>

MSP Number&#58; <input name="MSP" id="MSP" type="text"  style="width:235px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"   oscarDB=HINc><br>

Date Of Birth (dd/mm/yyyy)&#58; <input name="DOB" id="DOB" type="text"  style="width:147px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"   oscarDB=dobc><br>

</span>

<span style="position:absolute; left:350px; top:210px; font-family:sans-serif; font-size:14px;">

Street Address&#58; <input name="Address" id="Address" type="text"  style="width:250px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"  oscarDB=address><br>

City/Town&#58; <input name="City" id="City" type="text"  style="width:185px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"  oscarDB=city>

Province&#58; <input name="province" id="province" type="text"  style="width:30px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"  oscarDB=province><br>

Postal Code&#58; <input name="postal" id="postal" type="text"  style="width:100px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"  oscarDB=postal>

Fax&#58; <input name="fax" id="fax" type="text"  style="width:130px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;" ><br>

Tel&#58; (Home)<input name="HomePhone" id="HomePhone" type="text" class="noborder" style="width:120px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"  oscarDB=phone>

(bus)<input name="BusPh" id="BusPh" type="text" class="noborder" style="width:121px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"  oscarDB=phone2><br>

Email address&#58; <input name="email" id="email" type="text"  style="width:255px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"   oscarDB=email>

</span>

<div style="position:absolute; left:10px; top:350px; width:700px; font-family:sans-serif; font-size:14px;">

<span>Please describe in as much detail as possible, the information you want to access.  Indicate if you also want access to records about the disclosure of your information, or information of the person you are representing.  Be sure to give previous names if any.</span><br><br>

<table style='border:.75pt solid black; background:transparent; text-align:center; width:700px; border-collapse: collapse;'>
   <tr>
	<td style='border:.75pt solid black;'><span>&nbsp;</span></td>
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	<td style='border:.75pt solid black;'><span>&nbsp;</span></td>
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  <tr>
	<td style='border:.75pt solid black;'><span>&nbsp;</span></td>
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</table><br>

<span><b>Please indicate if you wish to</b><br>

<input name="Photocopy" id="Photocopy" type="text" class="XBox box1" > &nbsp; &nbsp; &nbsp; &nbsp; Receive a photocopy of the record.</span><br>

<span style="position:relative; left:32px;">Please note that a base fee of &#36; &nbsp;<input name="PhotocopyCost" id="PhotocopyCost" type="text"  style="width:40px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;" value=""> &nbsp;per page applies for each page copied. For convenience you may enclose this fee with your request.  You will be provided with an estimate of any additional costs .</span><br>

<span><input name="View" id="View" type="text" class="XBox box1" > &nbsp; &nbsp; &nbsp; &nbsp; View the original record without receiving a copy.</span><br>

<span style="position:relative; left:32px;"> Please ask for an estimate of the fee you will be charged for&#58;</span><br>

<span style="position:relative; left:32px;"><input name="Review1" id="Review1" type="text" class="XBox box1" > &nbsp; &nbsp; &nbsp; &nbsp; Review of the original by the Physician <b>and/or</b></span><br>

<span style="position:relative; left:32px;"><input name="Review2" id="Review2" type="text" class="XBox box1" > &nbsp; &nbsp; &nbsp; &nbsp; Supervision by physician or designated staff person for your review

</span><br>

<span>A deposit of 50&#37; of the fee may be required</span><br><br>

<input name="Signature" id="Signature" type="text"  style="width:300px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"   Value="x">

 &nbsp; &nbsp; &nbsp; &nbsp;<input name="Date" id="Date" type="text" class="noborder" style="width:300px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white; text-decoration:underline; border: 1px solid #000000;"   oscarDB=today> 


<br>
Patient Signature  &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Date (YYYY-MM-DD)

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<a rel="license" href="http://creativecommons.org/licenses/by-sa/3.0/deed.en_US"><img alt="Creative Commons License" style="border-width:0" src="http://i.creativecommons.org/l/by-sa/3.0/80x15.png" /></a><br><span xmlns:dct="http://purl.org/dc/terms/" property="dct:title">Request for Access to Personal Information eForm</span> by <span xmlns:cc="http://creativecommons.org/ns#" property="cc:attributionName">John Robertson </span> is licensed under a <a rel="license" href="http://creativecommons.org/licenses/by-sa/3.0/deed.en_US">Creative Commons Attribution-ShareAlike 3.0 Unported License</a>.<br>Permissions beyond the scope of this license may be available at <a xmlns:cc="http://creativecommons.org/ns#" href="http://www.oscarcanada.org/" rel="cc:morePermissions">http://www.oscarcanada.org/</a>.
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