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Www.theclinicnetwork.caFORM TCN02.V2Phone #: 184482626651Fax #: 18442620947 patientcare@theclinicnetwork.caPATIENT CONSENT FOR THE CLINIC NETWORK (TCN) TO DISCLOSE PERSONAL HEALTH INFORMATION TO A
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Begin by obtaining the consent-to-disclose-personal-health-information form.
02
Read the form carefully to understand the purpose and scope of the consent.
03
Fill in your personal information in the designated fields. This may include your name, contact details, and identification number.
04
Provide the name of the person or organization to whom you are granting consent to disclose your personal health information.
05
Specify the duration of the consent. You may choose to limit the time period during which the consent is valid.
06
Sign and date the form to acknowledge your understanding and agreement with the terms of the consent.
07
Review the completed form to ensure all information is accurate and complete.
08
Make a copy of the form for your personal records.
09
Submit the original signed form to the designated recipient or organization.

Who needs consent-to-disclose-personal-health-information?

01
Anyone who wishes to have their personal health information disclosed to a specific person or organization needs a consent-to-disclose-personal-health-information form.
02
This can include patients who want their medical records shared with another healthcare provider, individuals seeking to provide medical information to their insurance company, or individuals participating in research studies where their personal health information may be shared with researchers.
03
In general, anyone who wants to authorize the disclosure of their personal health information to a third party should obtain consent-to-disclose-personal-health-information.
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Consent-to-disclose-personal-health-information is a legal agreement that allows healthcare providers to share an individual's personal health information with others, such as family members, other healthcare providers, or insurance companies, under specific conditions.
Individuals who wish to allow their healthcare providers to share their personal health information must file consent-to-disclose-personal-health-information. This includes patients, guardians, or authorized representatives.
To fill out consent-to-disclose-personal-health-information, individuals must provide their personal details, specify the information to be disclosed, identify who it can be shared with, and sign the form to give consent.
The purpose of consent-to-disclose-personal-health-information is to protect patient privacy while allowing necessary information sharing for medical treatment, care coordination, and compliance with legal requirements.
The information reported on consent-to-disclose-personal-health-information typically includes the patient's name, date of birth, the specific health information to be disclosed, the name of the recipient(s), and the duration of consent.
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