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
* 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 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.
