1 Client Information

Client Legal Last Name

Client Legal First Name

Client Legal Second Name

Personal Health Number (PHN)

BirthDate(MM/DD/YYYY)

Other Provincial Health Number (If Applicable)

2 Power Of Attorney Or Legal Guardian (If Applicable) - Supporting Legal Documentation Required Indicating Relationship

Power Of Attorney Or Legal Guardian Legal Last Name

P.O.A. Or Legal Guardian Legal First Name

P.O.A. Or Legal Guardian Legal 2ND Name

3 Records Requested

Type Of Record(S) Required (Indicate Which Of the Records Below Are Required)

Medical History only (MSP)

Medical History With Diagnostic Code (MSP)

Drug History (Pharmacare)

Reason For Request

Motor Vehicle Accident (MVA)

Slip And Fall *

Other(Please Specify):

* For Slip and Fall requests to 3rd Party Liability, mail Authorization to:
3rd Party Liability Department, Ministry of Health Services, 2 - 1, 1515 Blanshard Street, Victoria BC V8W 3C8

Requested Dates Of Records

Start Date (MM/DD/YYYY)

End Date (MM/DD/YYYY)

Accident Information, If Applicable

Date of Accident (MM/DD/YYYY)

File / Reference # (If Applicable)

4 Name Of Person/Company And Address Where Records Are Being Sent

Person Or Company Receiving Records Medical Officer at Collaborative Solutions (WhoKnozMe) Named Client Caregiver or Care Team Member

APT / Unit

Street Number

Street Name

City

Prov

Postal Code

5 Payment (For Medical History (MSP) Records Only)

There is no charge to release your own medical records to you (the client) or your lawyer. However, a fee of $50 (CDN) is charged per year of record requested for all other third-party requests, including insurance companies and lawyers not representing the client. If third party request (other than your lawyer), please provide address below for invoicing.

Name Of Third Party

APT / Unit

Street Number

Street Name

City

Prov

Postal Code

6 Client Authorization - To Be Signed By The Client, Power Of Attorney, Or Legal Guardian

I, the client or power of attorney or the legal guardian named above, hereby authorize Health Insurance BC to release all medical records indicated above to the requestor named in section 4 at the address named in section 4.

By checking this box, I hereby revoke all previously signed authorizations for the release of Medical and/or Drug History Records.

Signature Of Client / Power Of Attorney / Legal Guardian

Signature Of Witness

Print Name Of Witness

Date Signed (MM/DD/YYYY)

By clicking the [I confirm] button, I acknowledge that I am signing this form electronically and agree that this is the legal equivalent of my handwritten signature. I will not at any time in the future claim that my electronic signature is not legally binding. The date of my electronic signature is the same as my acknowledgement.

Personal information on this form is collected under the authority of the Medicare Protection Act and will be used to process the disclosure(S) requested on this form, and is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act and may be disclosed only as provided by that Act. If you have any questions about the collection of this information, contact Health Insurance BC at the address or telephone numbers below.