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Patient rights

Patient Data Request Form

In accordance with the Nova Scotia Personal Health Information Act (PHIA)

  1. Step 1

    Complete the form

    Print it and fill in each section by hand.

  2. Step 2

    Bring photo ID

    The clinic verifies your identity before releasing any records.

  3. Step 3

    Submit to the clinic

    Mail or deliver it in person to the Privacy Officer at your clinic.

Patients have the right to request access to or correction of their personal health information (PHI) held by this clinic. Please complete this form to exercise your rights.

01Patient information

Full name
Date of birth (YYYY-MM-DD)
Phone number
Email address
Mailing address

02Request details

A copy of my personal health records.
A correction to my personal health records.
An inquiry into who has accessed my records (Audit Log Inquiry).

Description of specific information requested (e.g., specific dates, doctors, or records)

03Delivery method

Paper copy (pickup at clinic)
Secure email
In-person viewing

04Disclosure (optional)

Recipient name
Relationship

Identity verification

The clinic will verify your identity (e.g., government-issued photo ID) before releasing any records.

Submission instructions

Please mail or deliver this completed form in person to the Privacy Officer at your clinic.

Signature
Date

Provided by MDpass in accordance with PHIA.