Form HLTH5422 "Request for Information Release by the Minister of Health or Person Designated by the Minister, or by a College or a Regulatory Body for a Practitioner" - British Columbia, Canada

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Download Form HLTH5422 "Request for Information Release by the Minister of Health or Person Designated by the Minister, or by a College or a Regulatory Body for a Practitioner" - British Columbia, Canada

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REQUEST FOR INFORMATION RELEASE
By the Minister of Health or Person Designated by the Minister,
or by a College or a Regulatory Body for a Practitioner
under Section 23(1) of the Pharmaceutical Services Act
1.
Request Date
Required by Date
If urgent (required less than five days after the request date) provide reason
2.
Name and Title of Individual Requesting Data
Organization
3. Section 23(1) of the Pharmaceutical Services Act states:
23 (1) The minister may disclose, inside Canada, personal information under this Act for one or more of the following
purposes:
(b) to investigate or discipline a person regulated by a governing body of a health profession that has
authority, under an enactment of any jurisdiction, to investigate or discipline the person;
(c) to monitor, by a governing body of a health profession, the practice of a health profession that is, under
an enactment of any jurisdiction, regulated by that body;
Section 43 of the Pharmaceutical Services Act states:
43 (2) Without limiting section 22 (collection, use and disclosure of personal information) or 23 (disclosure of personal
information),
(b) a college, health care body and public insurer may collect and use personal information from the
minister for the purposes of determining any person’s compliance with an enactment that governs the
college, health care body or public insurer, as applicable.
(3) Without limiting section 22 or 23, the minister may
(b) disclose personal information to a college, health care body and public insurer for the purposes of
determining any person’s compliance with an enactment that governs the college, health care body or
public insurer, as applicable.
Describe how the data requested will be used in the review or investigation you are conducting, and how the data are
required for that purpose.
HLTH 5422 2017/12/08 PAGE 1 OF 4
REQUEST FOR INFORMATION RELEASE
By the Minister of Health or Person Designated by the Minister,
or by a College or a Regulatory Body for a Practitioner
under Section 23(1) of the Pharmaceutical Services Act
1.
Request Date
Required by Date
If urgent (required less than five days after the request date) provide reason
2.
Name and Title of Individual Requesting Data
Organization
3. Section 23(1) of the Pharmaceutical Services Act states:
23 (1) The minister may disclose, inside Canada, personal information under this Act for one or more of the following
purposes:
(b) to investigate or discipline a person regulated by a governing body of a health profession that has
authority, under an enactment of any jurisdiction, to investigate or discipline the person;
(c) to monitor, by a governing body of a health profession, the practice of a health profession that is, under
an enactment of any jurisdiction, regulated by that body;
Section 43 of the Pharmaceutical Services Act states:
43 (2) Without limiting section 22 (collection, use and disclosure of personal information) or 23 (disclosure of personal
information),
(b) a college, health care body and public insurer may collect and use personal information from the
minister for the purposes of determining any person’s compliance with an enactment that governs the
college, health care body or public insurer, as applicable.
(3) Without limiting section 22 or 23, the minister may
(b) disclose personal information to a college, health care body and public insurer for the purposes of
determining any person’s compliance with an enactment that governs the college, health care body or
public insurer, as applicable.
Describe how the data requested will be used in the review or investigation you are conducting, and how the data are
required for that purpose.
HLTH 5422 2017/12/08 PAGE 1 OF 4
4. PharmaNet Data Required
PATIENT INFORMATION
DATA VARIABLES
VARIABLE NAMES
REASON FOR REQUEST
PATIENT_NAME
Patient Name
CLNT_LABEL
PHN
CLNT_GENDER _LABEL
Gender
MRG_CLNT_BRTH_MTH
Date of birth
REGISTRANT INFORMATION
DATA VARIABLES
VARIABLE NAMES
REASON FOR REQUEST
PRAC_NAME
Registrant Name
PRSCR_PRAC_LABEL
Registrant identification number
(or PHARMACIST_ID)
Registrant identification reference (code
PRSCR_PRAC_LIC_BODY_
identifying the governing body from which
IDNT
practitioner receives licence)
PRSCR_PRAC_LIC_BODY
Description of Registrant’s governing body
RECORDS REQUESTED FOR (Choose one of the following)
All medications.
Medications for drugs listed in drug file provided by applicant
DRUG INFORMATION
DATA VARIABLES
VARIABLE NAMES
REASON FOR REQUEST
DINPIN (drug information number as per
HLTH_PROD_LABEL
drug list provided, field is mandatory)
DRUG_BRAND_NM
Canadian brand name
GEN_DRUG
Chemical/generic name
GEN_DRUG_STRGTH
Drug strength
UNIT_OF_MSR
Drug form units (e.g., ml, grams, each)
Dosage form description (e.g., aerosol, tablet,
GEN_DSG_FORM
capsule, liquid)
HLTH 5422 2017/12/08 PAGE 2 OF 4
MEDICATION/DISPENSING INFORMATION
DATA VARIABLES
VARIABLE NAMES
REASON FOR REQUEST
SRV_DATE
Date of service (date dispensed)
DSPD_QTY
Quantity dispensed
Days supply (estimate of number of days of
DSPD_DAYS_SPLY
prescription treatment)
DRUG_USE_DIR
Directions for use
DATA VARIABLES
VARIABLE
Other Information
5. Links to Data From Other Sources
Will PharmaNet data be linked to, or used in conjunction with, data from other source(s)?
Yes
No
If yes, state all other sources of data, including name of the all datasets to be linked. Attach copies of approvals obtained from the
stewards of the other data to be linked (if applicable), including a description of which fields are approved for use as linking variables
and which are not. Indicate which linking variables will be retained in the final analysis database, in addition to variables required for
analysis.
HLTH 5422 2017/12/08 PAGE 3 OF 4
6. Release of PharmaNet Data
Will there be any further release of PharmaNet data? To whom, and for what purpose? (include individuals’ names, titles, organization)
7. Format of Data
The data will be supplied in an Excel, or CSV format and delivered via SFTP, or other approved methods of delivery.
8. Confidentiality Declaration
Section 24 of the Act states that:
24 (1) A person to whom the minister discloses personal information under this Act must not use or disclose the
personal information for any purpose other than the purpose for which it was disclosed to the person, except
(a) in respect of his or her own personal information,
(b) in accordance with this Act or a regulation made under it,
(c) for the purposes of court proceedings, or
(d) for the purposes of enabling the college, a committee of the college or a person acting for the college to
exercise powers or perform duties under
(i) an enactment that applies to the college, or
(ii) the college bylaws.
(2) A person to whom the minister discloses personal information under this Act must comply with any limits
or conditions set, in writing, by the minister.
Signature of Person Making Request
Print Name
Date Signed
HLTH 5422 2017/12/08 PAGE 4 OF 4
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