Guideline for Completing the “Consent to Use Personal Health Information Form (PHI)”

The Personal Health Information Act (PHIA) permits trustee’s to use PHI without the consent of individual or a person permitted to exercise the rights of an individual, under specific circumstances.  This form is to be used only when a trustee is requesting to use PHI for a purpose that requires consent from the individual or a person permitted to exercise the rights of an individual.

Part 1: Consent from Patient / Client

Record the last name, first name, date of birth, health card number (the 9 digit PHIN in Manitoba or another jurisdictions health card number), address (in full) and phone numbers of the individual the information is about.

Part 2: Details of Consent

  • Indicate the name of the hospital, personal care home, clinic, community health centre, and/or program such as midwifery, home care, public health, mental health etc. that is requesting to use the PHI.
  • Specify the PHI that the trustee is requesting to use
  • Specify the purpose for which the information is to be used
  • Indicate if the consent for use is for the individual’s own information.  If so, check ‘yes’, if not, check ‘no’ and complete Part 3

Part 3: Person Permitted to Exercise the Rights of an Individual

Record the last name, first name, complete address and phone numbers of the person permitted to exercise the rights of an individual the information is about

Indicate your authority to exercise the rights of the individual from the following list.

A)  Any person with written authorization from the individual to act on the individual’s behalf;
B)  A proxy appointed by the individual under the Health Care Directives Act;
C)  A committee appointed for the individual under the Mental Health Act if the committee has the power to make health care decision on the individual’s behalf;
D)  A substitute decision maker for person care appointed for the individual under the Vulnerable Persons Living with a Mental Disability Act if the exercise of the right relates to the powers and duties of the substitute decision maker;
E)  The parent or guardian of an individual who is a minor, if the minor does not have the capacity to make health care decisions;
F)  If the individual is deceased, his or her Personal Representative

If it is reasonable to believe that no person listed in any clause above exists or is available, the adult person listed first in the the following clauses who is readily available and willing to act may exercise the rights of an individual who lacks the capacity to do so:

A)  The individual’s spouse, or common-law-partner, with whom the individual is cohabiting
B)  A son or daughter;
C)  A parent, if the individual is an adult;
D)  A brother or sister;
E)  A person with whom the individual is known to have a close personal relationship
F)  A grandparent;
G)  A grandchild
H)  An aunt or uncle
I)  A nephew or niece

Ranking:  The older or oldest of two or more relatives described in any clause of the above is to be preferred to another of those relatives.

Part 4: Sign Off

  • Indicate if the consent request is valid for one year, is valid for this request only or has an expiration date by placing a check mark in the appropriate box.  If the consent has an expiration date, specify the date.
  • Signature of the patient/client/resident or person permitted to exercise the rights of  the individual (as described in Parts 1 or 3)
  • Record the date consent is obtained
  • File the completed Consent to Use PHI Form on the patient’s /client’s health record

Consent to Use Personal Health Information

  • PART 1 - CONSENT FROM PATIENT / CLIENT

  • PART 2 - DETAILS OF CONSENT

  • (Name of location/site/program)
    If NO - complete Part 3
  • PART 3 - PERSON PERMITTED TO EXERCISE THE RIGHTS OF AN INDIVIDUAL

  • PART 4 - SIGN OFF

    I understand that this consent may be withdrawn or amended at any time. A withdrawal does not have a retroactive effect. The personal health information shall not be used except for the purpose specified on this consent.