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Release of Personal Information
Name
your full name
Address
your full address
Phone
number to best reach you
Date of Birth
(day/month/year)
Manitoba Health Card
6-digit number
Manitoba Health Card
9-digit number
I give Dr. Reece Malone Permission to Release my Private Information
Yes
No
Designated Recipient
name
recipient's address
recipient's phone number
recipient's fax (optional)
By typing my name, I hereby electronically sign this document
your full name
The named individual(s) and offices(s) are authorized to exchange information and are hereby released from any legal liability that arises as a result of the exchange of information.
Date
today's date
Note: This waiver is in effect for one year from the date of the request. Personal information is protected by the Personal Health Information Act and Protection of Privacy provisions of The Freedom of Information and Protection of Privacy Act.
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