To request a copy of your health record a ‘Consent to Disclose Personal Health Information’ form must be completed by the patient/Substitute Decision Maker/Executor and the original submitted to the CKHA Release of Information Specialist via mail/drop off/email, along with pre-payment (see fee schedule below).

To avoid request delays, please ensure the form is completed in full, signed, dated and witnessed. If you are requesting information as the authorized Substitute Decision Maker/Executor for a patient who is incapable/deceased, you will need to verify your role by providing the necessary documentation (e.g. copy of Power of Attorney for Personal Care document, Will).

For further instructions, please read page 2 of the ‘Consent to Disclose Personal Health Information’. 

To contact the office, call 519.352.6400 x 6374 or email ckphipa@ckha.on.ca