Consent to Disclose Personal Health Information
Use the form below to authorize Apple Hills Medical Associates to share your personal health information with a designated individual or organization. Download the PDF form, complete it, and return it to our office.
About This Form
Authorizing the Release of Your Health Information
This form allows you to give Apple Hills Medical Associates written consent to disclose your personal health information to a person or organization of your choosing. This may include sharing records with a specialist, a family member, an insurer, or another care provider.
Completing this form ensures your privacy is protected and that any disclosure of your health information is made only with your explicit, documented authorization — in accordance with Ontario's Personal Health Information Protection Act (PHIPA).
Note: This is a separate form from the Email Consent Form, which authorizes communication by email. If you wish to consent to receiving health information by email, please visit the Email Consent Form page.
PDF Document
Download Your Consent Form
The Consent to Disclose Personal Health Information form is available as a PDF document. Print, complete, and return it to our office in person or by fax.
CONSENT TO DISCLOSE PERSONAL HEALTH INFORMATION.pdf
PDF document — requires Adobe Acrobat Reader or compatible PDF viewer
Next Steps
Returning Your Completed Form
Once you have completed the consent form, you may return it to Apple Hills Medical Associates using any of the following methods:
In Person
Bring the completed form to our office during regular business hours.
By Fax or Mail
Contact our office for fax and mailing details.
For questions about this form or your privacy rights, please contact our office or send us a message.
Patient Resources
Other Patient Forms & Resources
Email Consent Form
Authorize Apple Hills Medical Associates to communicate with you by email regarding your health care.
View FormEnrolment Forms
New to Apple Hills Medical Associates? Complete your patient enrolment forms to register with our practice.
View FormsPrivacy Policy
Learn how Apple Hills Medical Associates collects, uses, and protects your personal health information.
Read PolicyWe're Here to Help
Have Questions About Your Privacy?
Our team is happy to help you understand your rights and guide you through the consent process. Reach out any time during office hours.