Templates and forms

Templates and forms

Templates and forms related to PHIA can be modified to suit individual medical practices.

Complying with the Personal Health Information Act: Templates and forms for physicians (50 pgs. MSWord document) is a companion document to Complying with PHIA: A practical guide for physicians. 
 

Templates

This section contains policy templates and other kinds of templates (notice, breach letter) that must be customized by each practice to reflect their individual information-related practices. 

  1. Notice of Purposes Template Microsoft Word document (EN) Microsoft Word document (FR)
  2. Retention Schedule Microsoft Word document
  3. Written Privacy Statement Template Microsoft Word document
  4. Privacy Policy Template Microsoft Word document
  5. Safeguards Policy Template Microsoft Word document
  6. Breach Letter Template to Patients Microsoft Word document
  7. Complaints Policy Template Microsoft Word document
  8. Confidentiality Agreement Microsoft Word document


Forms to be completed by custodian

This section contains forms that should be completed by a custodian for a variety of purposes under PHIA.

  1. Breach Reporting Form for Review Officer Microsoft Word document
  2. Review Office Notification Form for Research Microsoft Word document
  3. Fee Estimate for Access Microsoft Word document
  4. Response to Request for Access – Granted in Full Microsoft Word document
  5. Response to Request for Access – Granted in Part Microsoft Word Document
  6. Response to Request for Correction – Granted in Full Microsoft Word document
  7. Response to Request for Correction – Granted in Part  Microsoft Word document
  8. Response to Request for Correction – Not Granted Microsoft Word document
  9. Fee schedule Microsoft Word document

Forms to be completed by patients

This section contains forms a custodian provides to a patient. The patient completes the form. 

  1. Request for Access to Personal Health Information Microsoft Word document
  2. Request for Correction of Personal Health Information Microsoft Word document
  3. Request for a Fee Waiver Microsoft Word document
  4. Complaint Form Microsoft Word document

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