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. Are you: Filing a privacy complaint about your own personal health information The substitute decision-maker (such as a parent or guardian) for someone who is filing a privacy complaint about their personal health information 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. Skip this section if you are not a substitute decision-maker. 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 the health information custodian, if applicable Address Unit City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone Number Email File number for your complaint (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. We may need additional personal health information to process your complaint. Do you consent to the IPC looking at or asking for the personal health information we need to process your complaint? 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 health information custodian). Details of your complaint Please select all the boxes that explain why you are making the complaint: The health information custodian the complaint relates to has inappropriately collected, used and/or disclosed (shared) my personal health information Other, please explain: Enter other… Please provide a detailed description of your complaint. Your description should include the what, when, who, how, where and why of what happened. If you need more space, please attach as many pages as necessary at the end of this form. Have you communicated with the health information custodian about your complaint? If so, please explain. Resolution of your complaint Do you have a suggestion about how your complaint could be resolved? 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 health information custodian to improve its privacy practices, or stop an unauthorized use or disclosure of your personal health information, for example,The IPC cannot order disciplinary measures against employees of the health information custodian you are complaining about (such as requiring the health information custodian to fire an employee) or order it to pay you financial compensation (money). Attachments Please attach any documents about your complaint or evidence of your role as a substitute decision-maker. The following documents have been attached (if applicable): 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. Are you: Filing a privacy complaint about your own personal health information The substitute decision-maker (such as a parent or guardian) for someone who is filing a privacy complaint about their personal health information 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. Skip this section if you are not a substitute decision-maker. 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 the health information custodian, if applicable Address Unit City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone Number Email File number for your complaint (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. We may need additional personal health information to process your complaint. Do you consent to the IPC looking at or asking for the personal health information we need to process your complaint? 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 health information custodian). Details of your complaint Please select all the boxes that explain why you are making the complaint: The health information custodian the complaint relates to has inappropriately collected, used and/or disclosed (shared) my personal health information Other, please explain: Enter other… Please provide a detailed description of your complaint. Your description should include the what, when, who, how, where and why of what happened. If you need more space, please attach as many pages as necessary at the end of this form. Have you communicated with the health information custodian about your complaint? If so, please explain. Resolution of your complaint Do you have a suggestion about how your complaint could be resolved? 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 health information custodian to improve its privacy practices, or stop an unauthorized use or disclosure of your personal health information, for example,The IPC cannot order disciplinary measures against employees of the health information custodian you are complaining about (such as requiring the health information custodian to fire an employee) or order it to pay you financial compensation (money). Attachments Please attach any documents about your complaint or evidence of your role as a substitute decision-maker. The following documents have been attached (if applicable): 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
