Windsor Regional Hospital - Release of Information

*Name of Patient / Substitute Decision Maker:

*Email Address:

*Contact Phone #:

ext.

*Leave Message:

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*Windsor Regional Hospital is authorized to:

Windsor Regional Hospital is authorized toRelease Information
Collect Information

Records pertaining to the admission(s) / visit(s) from:

*Start Date:

*End Date:

*Institution compiled at:

*Request:

RequestRequested by (Specific Name, Unit, or Department)
Requestor Agency (e.g. Insurance Company, Lawyer, Physician Office)

Requested by:

Requestor Agency Name & Department:

Address:

*This information will be used for the purpose of:

This information will be used for the purpose ofFurther Medical Treatment
Insurance Claim
Litigation
Estate Settlement
Physician Reference
Mental Health Assessment and/or Treatment
Other

Other (please specify):

Upload a scanned copy of your valid OHIP card or Photo ID:

x

Delete Current File

Consent:

I understand the private and confidential nature of this information and agree that it will be used only for the stated purpose(s). I further absolve the information – releasing the Hospital named above of any responsibility for carrying out this directive. This authorization will be valid for 90 days unless specified otherwise.

I am aware that I may withdraw this consent at any time and I agree to waive any and all claims against Windsor Regional Hospital in connection with the disclosure of this personal health information.

I understand that by pressing submit, your personal information will be stored on an encrypted secure server. The requested documentation of the medical record will be sent via email or fax to the destination you have identified above. Windsor Regional Hospital ("WRH") is not responsible for emails inadvertently sent to the wrong recipient by the mistyping of an email address/number or using an autocorrect feature. By submitting this form, you hereby release WRH from any and all claims and liability in connection with the disclosure of this personal health information.