CONSENT TO DISCLOSE INDIVIDUALLY IDENTIFYING PERSONAL AND/OR HEALTH INFORMATION Authorized by: The Health Information Act (HIA) The Freedom of Information and Protection of Privacy Act (FOIP Act) Full Legal Name: Client Also As: Information: I authorize my individually identifying personal and/or health information related to: to be disclosed by: (name of custodian / public body) In accordance with: HIA s.34 The FOIP Act s.40(1)(d) and section 7(2) of the FOIP Regulation to: (name of recipient / role / organization) for the following purpose(s) and how the information may be used: (description of the information) I understand why I have been asked to disclose my individually identifying information, and am aware of the risks and benefits of consenting, or refusing to consent, to the disclosure of my individually identifying information. I understand that I may revoke this consent in writing or electronically at any time. Effective Date: Expiry date under HIA (if any) Signature of client/authorized representative.* X *If you are signing on behalf of the client, the following information must be provided: Print Name of Authorized Representative:___________________________________ Print Source of Representative’s Authority (HIA s.104 or FOIP Act s.84(1) Health and Safety FAQ How does information Sharing information appropriately results in increased sharing support the safety communication and more informed decision-making. and wellbeing of Albertans? It allows organizations to share personal or health information for case planning to identify critical supports and services that meet the needs of Albertans and their family or caregivers. It enables risks to be managed properly by ensuring organizations are informed about urgent supports an Albertan may require. It also helps identify any health or safety risks the Albertan, staff or others could experience.
CONSENT TO DISCLOSE INDIVIDUALLY IDENTIFYING PERSONAL AND/OR HEALTH INFORMATION Authorized by: The Health Information Act (HIA) The Freedom of Information and Protection of Privacy Act (FOIP Act) Client Information: Full Legal Name: Also As: I authorize my individually identifying personal and/or health information related to: to be disclosed by: (name of custodian / public body) In accordance with: HIA s.34 The FOIP Act s.40(1)(d) and section 7(2) of the FOIP Regulation to: (name of recipient / role / organization) for the following purpose(s) and how the information may be used: (description of the information) I understand why I have been asked to disclose my individually identifying information, and am aware of the risks and benefits of consenting, or refusing to consent, to the disclosure of my individually identifying information. I understand that I may revoke this consent in writing or electronically at any time. Effective Date: Expiry date under HIA (if any) Signature of client/authorized representative.* X *If you are signing on behalf of the client, the following information must be provided: Print Name of Authorized Representative:___________________________________ Print Source of Representative’s Authority (HIA s.104 or FOIP Act s.84(1) Health and Safety FAQ How does information sharing support the safety and wellbeing of Albertans? Sharing information appropriately results in increased communication and more informed decision-making. It allows organizations to share personal or health information for case planning to identify critical supports and services that meet the needs of Albertans and their family or caregivers. It enables risks to be managed properly by ensuring organizations are informed about urgent supports an Albertan may require. It also helps identify any health or safety risks the Albertan, staff or others could experience.
information-sharing-toolkit.docx