Do you have a patient support representative at the clinic?

This completed form gives a trusted family member or friend(s) the ability to support you and communicate with medical staff. You can designate one person or multiple people.

There are 4 levels of authorization that you can choose from:

• All my rights under the Health Information Act (appointments/ results/ forms), OR
• My right to access all records containing my health information, OR
• Other ─ Example: Book or cancel an appointment, OR
• The rights that are conferred on me under the Health Information Act regarding the following question: Example: Receive lab results

You can also choose the duration of the authorization:

• The present authorization will be in effect indefinitely.
• The present authorization will be in effect until _______________________, 20______.

All patients should have a patient support representative at the clinic; the following demographic groups are exceptionally important:

• Young adults, once a child is 18, the parent can no longer speak on their behalf.
• Aged adults, if family or caregivers are attending appointments with them.
• Young patients that are brought to appointments by caregivers or family members.
• Youth of co-parenting families.

This form is available at our reception desk, and staff is available to assist you in completing the form.

This form is clinic specific and will not provide a patient support representative at the Drumheller Health Centre.