SUBMIT A RELEASE OF PATIENT INFORMATION FORM USING OUR ONLINE REQUEST FORM

SUBMIT A RELEASE OF PATIENT INFORMATION FORM BY FAX, MAIL, or EMAIL

Hand-draw signatures are required.
Typed signatures will not be accepted.

Allow up to four weeks for your request to be processed.

The transfer of records is considered an uninsured service.
The patient is responsible for the $30.00 fee incurred for the transfer of an entire medical or counselling record.
The $30.00 fee may be waived if only a select few documents are requested (e.g., a single laboratory report only, vaccine record only, records from a single specific issue only).
Payment can be made by cheque or through Mosaic.
An invoice with payment instructions will be mailed to the patient’s address provided on the Release of Information request form.

If it is requested that records be transferred by email, please acknowledge the risks entailed with exchanging personal information by email, as outlined in the Patient Agreement.

If you would like your records transferred to a legal professional, the request must come directly from the law office that you are working with.