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 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 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.
* 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 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.
