"Newfoundland and Labrador Prescription Drug Program Release of Personal Information Consent Form" - Newfoundland and Labrador, Canada

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Department of Health and Community Services
Newfoundland and Labrador Prescription Drug Program
NEWFOUNDLAND AND LABRADOR PRESCRIPTION DRUG PROGRAM RELEASE
OF PERSONAL INFORMATION CONSENT FORM
1. I,___________________________________ hereby give my informed consent to the
(client name as it appears on MCP card)
Pharmaceutical Services Division of the Department of Health and Community Services and
its service provider to disclose any or all of my personal health information in its possession
to______________________________________ my _______________________________
(insert individual or organization name)
(son, daughter, husband, caregiver, etc)
for the purpose of enabling or assisting me to receive health care benefits under the
Newfoundland and Labrador Prescription Drug Program.
2. This consent survives until terminated or withdrawn, in writing by me.
______________________________
____________________________________
Client Signature
Witness Signature
_________________________________
___
Witness Name (Please print)
Dated at _____________________________, this ____ day of _________________, _____.
(Community)
(Day)
(Month)
(Year)
_____________________________
_____________________________________________
Client MCP Number
Address
_____________________________
_____________________________________________
Social Insurance Number
City
_____________________________
_____________________________________________
Date of Birth
Telephone Number
Upon completion, return to the address below or fax to: 709-729-2851. For questions or concerns
please call: 709-729-6507 or toll free at: 1-888-222-0533.
Newfoundland and Labrador Prescription Drug Program
Department of Health and Community Services
P.O. Box 8700, St. John’s, NL A1B 4J6
Department of Health and Community Services
Newfoundland and Labrador Prescription Drug Program
NEWFOUNDLAND AND LABRADOR PRESCRIPTION DRUG PROGRAM RELEASE
OF PERSONAL INFORMATION CONSENT FORM
1. I,___________________________________ hereby give my informed consent to the
(client name as it appears on MCP card)
Pharmaceutical Services Division of the Department of Health and Community Services and
its service provider to disclose any or all of my personal health information in its possession
to______________________________________ my _______________________________
(insert individual or organization name)
(son, daughter, husband, caregiver, etc)
for the purpose of enabling or assisting me to receive health care benefits under the
Newfoundland and Labrador Prescription Drug Program.
2. This consent survives until terminated or withdrawn, in writing by me.
______________________________
____________________________________
Client Signature
Witness Signature
_________________________________
___
Witness Name (Please print)
Dated at _____________________________, this ____ day of _________________, _____.
(Community)
(Day)
(Month)
(Year)
_____________________________
_____________________________________________
Client MCP Number
Address
_____________________________
_____________________________________________
Social Insurance Number
City
_____________________________
_____________________________________________
Date of Birth
Telephone Number
Upon completion, return to the address below or fax to: 709-729-2851. For questions or concerns
please call: 709-729-6507 or toll free at: 1-888-222-0533.
Newfoundland and Labrador Prescription Drug Program
Department of Health and Community Services
P.O. Box 8700, St. John’s, NL A1B 4J6