Form YG6364 "Request for Access to Personal Information/Personal Health Information Records" - Yukon, Canada

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Download Form YG6364 "Request for Access to Personal Information/Personal Health Information Records" - Yukon, Canada

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REQUEST FOR ACCESS TO PERSONAL INFORMATION/
PERSONAL HEALTH INFORMATION RECORDS
SECTION 1: ABOUT YOU
First Name
Last Name
Date of Birth (YYYY/MM/DD)
Company/Organization (if applicable)
Address
City/Town
Postal Code
Phone Number (day)
Phone Number (evening)
If you are acting on behalf of another individual as their substitute decision-maker, please complete Section 2. If you
are requesting your own personal health information, go to Section 3.
SECTION 2: SUBSTITUTE DECISION-MAKER INFORMATION
First Name
Last Name
Date of Birth (YYYY/MM/DD)
Address
City/Town
Postal Code
Phone Number (day)
Phone Number (evening)
I am the substitute decision-maker and authorized to make decisions on the individual’s behalf.
* Please provide a copy of your statutory declaration form.
SECTION 3: ABOUT YOUR REQUEST
Do you want to:
Do you want to:
Do you want an Estimate of Fees?
Receive a copy of the records?
Pick up your information?
Yes
OR
OR
OR
Examine the records?
Receive it by Registered Mail?
No
SECTION 4: ABOUT THE INFORMATION YOU WANT
What records do you want to access? Please give as much detail as possible. If you need more space, please attach
a separate sheet of paper.
What is the time period of the records? Please give specific dates. (See reverse for details)
SECTION 5: YOUR SIGNATURE
Signature
Date
SECTION 6: FOR OFFICE USE ONLY
Reference # H- ______________________ Date Received:
Response Deadline:
Requestor identity verified via:
Photo ID viewed
Other method (please document)
Initials ________
YG(6364)F2 09/2016
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REQUEST FOR ACCESS TO PERSONAL INFORMATION/
PERSONAL HEALTH INFORMATION RECORDS
SECTION 1: ABOUT YOU
First Name
Last Name
Date of Birth (YYYY/MM/DD)
Company/Organization (if applicable)
Address
City/Town
Postal Code
Phone Number (day)
Phone Number (evening)
If you are acting on behalf of another individual as their substitute decision-maker, please complete Section 2. If you
are requesting your own personal health information, go to Section 3.
SECTION 2: SUBSTITUTE DECISION-MAKER INFORMATION
First Name
Last Name
Date of Birth (YYYY/MM/DD)
Address
City/Town
Postal Code
Phone Number (day)
Phone Number (evening)
I am the substitute decision-maker and authorized to make decisions on the individual’s behalf.
* Please provide a copy of your statutory declaration form.
SECTION 3: ABOUT YOUR REQUEST
Do you want to:
Do you want to:
Do you want an Estimate of Fees?
Receive a copy of the records?
Pick up your information?
Yes
OR
OR
OR
Examine the records?
Receive it by Registered Mail?
No
SECTION 4: ABOUT THE INFORMATION YOU WANT
What records do you want to access? Please give as much detail as possible. If you need more space, please attach
a separate sheet of paper.
What is the time period of the records? Please give specific dates. (See reverse for details)
SECTION 5: YOUR SIGNATURE
Signature
Date
SECTION 6: FOR OFFICE USE ONLY
Reference # H- ______________________ Date Received:
Response Deadline:
Requestor identity verified via:
Photo ID viewed
Other method (please document)
Initials ________
YG(6364)F2 09/2016
1 of 2
HOW TO COMPLETE THIS FORM
If you need help completing this form, contact Health and Social Services’ Access to Information (ATI) Office at:
Phone (867) 667-5919 or (867) 667-3188
Toll-free in Yukon 1-800-661-0408 (ext. 5919 or ext. 3188)
Email healthprivacy@gov.yk.ca
Section 1: About you
Enter your last name and first name, date of birth, complete mailing address and your daytime and evening telephone
numbers. The ATI Office may need to contact you if they have any questions about your request.
Section 2: Substitute Decision Maker Information
If you are requesting records for another person, as their Substitute Decision-Maker, you will be asked to provide a
statutory declaration form.
Section 3: About your request
If you need help to find out what records Health and Social Services has, please contact the department’s ATI Office.
1. If you are making a request for your own personal information/personal health information you will have to provide
proof of your identity before the records are released to you. For example, we may ask to view a piece of photo
identification or ask you some questions.
2. Do you want to receive a copy of the records or examine the records? Check the appropriate box.
3. Do you want to pick up your information or have your information sent by Registered Mail? Check appropriate box.
Please note all correspondence sent from this office is sent via Registered Mail.
4. Do you want to receive an Estimate of Fees? Check the appropriate box.
You may be required to pay a fee for printing or photocopying (.15/page), and a service charge (of $6.25/15 minutes)
to locate, retrieve and prepare the information.
Section 4: About the Information you want to access
1. What personal information/personal health information are you requesting? Please be as specific as possible in
describing the records. The more specific your request, the quicker and more accurately it can be answered. If you
need more space, please continue your description on a separate sheet of paper and attach it to this request form.
Please be sure that you give:
your full name
any other names that you have previously used; and
any identifying number that relates to the records, such as your personal health number, case number or other
identification number.
2. Enter the time period of the requested records. For example, if you are requesting records for the period
January 1, 1998 to August 31, 1999 enter those dates in the space provided. If you want records from
August 1996 to the present, enter “August 1996 to the present.”
Section 5: Your signature
Sign and date the form and send it to the ATI Office.
Physical Locations
Mailing Address
Crocus Ridge Place
OR
ATIPP Office (Whitehorse)
Attn: ATI Office
#1 Hospital Road – 2nd Floor
Yukon Government Main Admin Building
Health and Social Services (H-1)
Whitehorse, Yukon
2071 Second Ave. (Lower Floor)
Box 2703
Whitehorse, Yukon
Whitehorse, Yukon Y1A 2C6
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