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My Humber Health Proxy Consent and Access Form Health Information Services 1235 Wilson Avenue, Toronto, ON M3M 0B2 (P) 4162421000 ext. 82300 (F) 4162421085 Email: roi@hrh.ca My Humber Health is a

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How to fill out my humber health proxy

01

Obtain a copy of the My Humber Health Proxy form.

02

Fill out your personal information including your name, address, date of birth, and contact information.

03

Indicate the name of the person you are appointing as your health proxy and their contact information.

04

Specify any limitations or special instructions for your health proxy.

05

Sign and date the form in the presence of a witness who must also sign and date the form.

06

Make copies of the completed form for yourself, your health proxy, and your healthcare providers.

Who needs my humber health proxy?

01

Anyone who wants to ensure their healthcare wishes are known and respected in case they are unable to communicate or make decisions for themselves.

02

Individuals with chronic conditions or serious illnesses who may need someone to make medical decisions on their behalf.

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What is my humber health proxy?

Your Humber Health Proxy is a legal document that allows you to appoint someone to make healthcare decisions on your behalf if you are unable to do so.

Who is required to file my humber health proxy?

You are required to file your Humber Health Proxy if you want to ensure that your healthcare wishes are followed in case you become incapacitated.

How to fill out my humber health proxy?

You can fill out your Humber Health Proxy by clearly stating your healthcare preferences and appointing a trusted individual to make decisions for you.

What is the purpose of my humber health proxy?

The purpose of your Humber Health Proxy is to ensure that your medical wishes are respected and followed if you are unable to communicate them yourself.

What information must be reported on my humber health proxy?

Your Humber Health Proxy must include your appointed healthcare agent, specific instructions for your medical care, and any other relevant healthcare preferences.

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