Share to Facebook Share to X Share to LinkedIn Share to Email Download the PDF version of this form You must have JavaScript enabled to use this form. COMPLAINT UNDER THE PERSONAL HEALTH INFORMATION PROTECTION ACT (PHIPA)Note: A “health information custodian” in PHIPA is a person or organization that has custody or control of personal health information for the purpose of health care or other health-related duties. Your Information Last Name First Name Middle Initial(s) Preferred Name Address Unit City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone Number If you consent to the IPC contacting you by phone including leaving a voicemail message, please provide your phone number. Email If you wish to communicate with the IPC by email, please provide your email address. Please note that email communication is optional and the security of email communication cannot be guaranteed. Substitute decision-maker information Please describe your role and explain your relationship. Skip this section if you are not a substitute decision-maker.If you are a substitute decision-maker (such as a parent or guardian) making a complaint on behalf of someone else, please describe your role and explain your relationship. It may be necessary to provide documentation to prove you are authorized to act for the individual. Please attach this documentation if you have it, at the end of this form. Representative Information Representative is a: Lawyer Other person Last Name First Name Middle Initial(s) Preferred Name Address Unit City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone Number Email Skip this section if you do not have a representative.You may represent yourself in a complaint to the IPC, or have someone else (such as a lawyer or another person) represent you.If someone is representing you, and you authorize that person to act on your behalf, and you consent to the IPC to contacting them (including through email) and exchanging information about this complaint, please fill out the contact information below. Information about health information custodian your complaint relates to Name of health information custodian your complaint relates to Name of contact person at organization, if applicable Address Unit City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone number Email address File number for your request (if applicable) Sharing your information If you do not consent to share your complaint information, please explain why below. We will consider whether we can properly address your complaint without sharing this information. If you do not consent to share your complaint information, please explain why below. We will consider whether we can properly address your complaint without sharing this information. If you do not consent to share your complaint information, please explain why below. We will consider whether we can properly address your complaint without sharing this information. Yes No We would like to share your complaint with the health information custodian you have complained about, so the health information custodian understands the reasons for your complaint and the IPC can process your complaint.By filing this complaint, you consent to share your name, this complaint form, and all attachments provided with this complaint form to all of the parties to this complaint (including the custodian). Details of your complaint Please select all the boxes that explain why you are making the complaint: Deemed Refusal – It is more than 30 days since I made my request and I have not received a response. Exemptions – The health information custodian has exempted all or part of the requested records and I believe that more of them should be disclosed. Fee/Fee Estimate – The health information custodian sent me an access decision that included a fee or fee estimate that I feel is excessive. Fee Waiver – The health information custodian has refused to grant my request to waive the fees. Reasonable Search – The health information custodian indicated that some or all of the requested records do not exist and I believe that more records do exist. Expedited Access – The health information custodian refused my request to process my access request on an urgent basis in less than 30 days. Correction – The health information custodian has refused to make corrections to my personal health information. Other, please explain: Enter other… Have you communicated with the custodian about your complaint? If so, please explain. Resolution of your complaint Do you have a suggestion about how your complaint could be resolved? In certain circumstances, the IPC will make an order to resolve a complaint. However, it is important to note that most complaints before the IPC are resolved informally and do not result in an order. The IPC can order a custodian to grant access to requested records, order a custodian to respond to an access request, etc.The IPC cannot order disciplinary measures against employees of the custodian you are complaining about (such as requiring the custodian to fire an employee) or order it to pay you financial compensation (money). Attachments Attach the following documents (if you have them): Copy of the request Copy of the health information custodian’s decision No documents are available Proof of authorization to act on behalf of the complainant (for substitute decision-makers) Other documents (please describe): Enter other… Attachments Unlimited number of files can be uploaded to this field.100 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Option 1Send this form now.Option 2Print the form and email to @email or mail to:RegistrarInformation and Privacy Commissioner/Ontario1400-2 Bloor Street EastToronto, OntarioM4W 1A8What happens next? Someone from our intake team will contact you to discuss your complaint.Find out more about the complaint process.You can also contact our office by email at @email, by phone at 416-326-3333, toll-free at 1-800-387-0073 if you have questions. Leave this field blank
Share to Facebook Share to X Share to LinkedIn Share to Email Download the PDF version of this form You must have JavaScript enabled to use this form. COMPLAINT UNDER THE PERSONAL HEALTH INFORMATION PROTECTION ACT (PHIPA)Note: A “health information custodian” in PHIPA is a person or organization that has custody or control of personal health information for the purpose of health care or other health-related duties. Your Information Last Name First Name Middle Initial(s) Preferred Name Address Unit City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone Number If you consent to the IPC contacting you by phone including leaving a voicemail message, please provide your phone number. Email If you wish to communicate with the IPC by email, please provide your email address. Please note that email communication is optional and the security of email communication cannot be guaranteed. Substitute decision-maker information Please describe your role and explain your relationship. Skip this section if you are not a substitute decision-maker.If you are a substitute decision-maker (such as a parent or guardian) making a complaint on behalf of someone else, please describe your role and explain your relationship. It may be necessary to provide documentation to prove you are authorized to act for the individual. Please attach this documentation if you have it, at the end of this form. Representative Information Representative is a: Lawyer Other person Last Name First Name Middle Initial(s) Preferred Name Address Unit City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone Number Email Skip this section if you do not have a representative.You may represent yourself in a complaint to the IPC, or have someone else (such as a lawyer or another person) represent you.If someone is representing you, and you authorize that person to act on your behalf, and you consent to the IPC to contacting them (including through email) and exchanging information about this complaint, please fill out the contact information below. Information about health information custodian your complaint relates to Name of health information custodian your complaint relates to Name of contact person at organization, if applicable Address Unit City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone number Email address File number for your request (if applicable) Sharing your information If you do not consent to share your complaint information, please explain why below. We will consider whether we can properly address your complaint without sharing this information. If you do not consent to share your complaint information, please explain why below. We will consider whether we can properly address your complaint without sharing this information. If you do not consent to share your complaint information, please explain why below. We will consider whether we can properly address your complaint without sharing this information. Yes No We would like to share your complaint with the health information custodian you have complained about, so the health information custodian understands the reasons for your complaint and the IPC can process your complaint.By filing this complaint, you consent to share your name, this complaint form, and all attachments provided with this complaint form to all of the parties to this complaint (including the custodian). Details of your complaint Please select all the boxes that explain why you are making the complaint: Deemed Refusal – It is more than 30 days since I made my request and I have not received a response. Exemptions – The health information custodian has exempted all or part of the requested records and I believe that more of them should be disclosed. Fee/Fee Estimate – The health information custodian sent me an access decision that included a fee or fee estimate that I feel is excessive. Fee Waiver – The health information custodian has refused to grant my request to waive the fees. Reasonable Search – The health information custodian indicated that some or all of the requested records do not exist and I believe that more records do exist. Expedited Access – The health information custodian refused my request to process my access request on an urgent basis in less than 30 days. Correction – The health information custodian has refused to make corrections to my personal health information. Other, please explain: Enter other… Have you communicated with the custodian about your complaint? If so, please explain. Resolution of your complaint Do you have a suggestion about how your complaint could be resolved? In certain circumstances, the IPC will make an order to resolve a complaint. However, it is important to note that most complaints before the IPC are resolved informally and do not result in an order. The IPC can order a custodian to grant access to requested records, order a custodian to respond to an access request, etc.The IPC cannot order disciplinary measures against employees of the custodian you are complaining about (such as requiring the custodian to fire an employee) or order it to pay you financial compensation (money). Attachments Attach the following documents (if you have them): Copy of the request Copy of the health information custodian’s decision No documents are available Proof of authorization to act on behalf of the complainant (for substitute decision-makers) Other documents (please describe): Enter other… Attachments Unlimited number of files can be uploaded to this field.100 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Option 1Send this form now.Option 2Print the form and email to @email or mail to:RegistrarInformation and Privacy Commissioner/Ontario1400-2 Bloor Street EastToronto, OntarioM4W 1A8What happens next? Someone from our intake team will contact you to discuss your complaint.Find out more about the complaint process.You can also contact our office by email at @email, by phone at 416-326-3333, toll-free at 1-800-387-0073 if you have questions. Leave this field blank
