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Medical Records Release Authorization
NextGen Docs form ND-1058. Search ND-1058 on docs.ngz.ca to make this document again.
Give your doctor, clinic or hospital written permission to send your health records to someone else.
Start this document FreeHow it works
What you will fill in
- Patient's full name
- Patient's date of birth
- Send records from
- Send records to
- Which records?
- Which dates or which reports?
- Date signed
Good to know
- In Ontario, the Personal Health Information Protection Act (PHIPA) lets you choose who sees your health records. You can withdraw this permission in writing at any time.
- A clinic may charge a reasonable fee to copy and send records.
- Bring photo ID if you hand it in yourself.
Help in your language
Every question comes with help like this. For example, “Patient's full name”:
English: The person whose records will be sent.
اردو: مریض کا پورا نام۔
ਪੰਜਾਬੀ: ਮਰੀਜ਼ ਦਾ ਪੂਰਾ ਨਾਮ।
हिन्दी: मरीज़ का पूरा नाम।
Français: La personne dont le dossier sera envoyé.
Questions people ask
How much does the Medical Records Release Authorization cost?
It is free to fill in, preview and download.
Can I fill in the Medical Records Release Authorization in Urdu, Punjabi, Hindi or French?
Yes. The finished document is in English, but every question has plain help in English, Urdu, Punjabi, Hindi and French, and you can speak your answers.
Do I need a lawyer?
Many people use this document on their own. If your situation is complicated, or a lot of money or your home is involved, talk to a lawyer or licensed paralegal. In Ontario, the Law Society Referral Service (findlegalhelp.ca) gives a free 30-minute consultation.
Is my information private?
Only you can see your answers. They are saved on your device, and in your own account if you sign in, so you can finish on another device. NextGen Docs is not a law firm and does not give legal advice.