Patient Request for Correction to Personal Information
If you believe your patient records with our office are inaccurate or incomplete, you (or
your legally authorized representative) may ask us to correct the error or omission. Our
Privacy Officer or staff member will explain the process.
Within 30 working days of receiving your completed request for correction to personal
information (see attached form), we will correct or amend any information in your patient
record that we have verified to be inaccurate or incomplete, then send a copy of the
corrected record to each organization to which the inaccurate or incomplete information
was disclosed within the past year.
If we decide that no correction is necessary, our Privacy Officer will explain the reasons
for this. We will not correct or change an opinion, including a professional or expert
opinion. We will note your requested correction and reasons for not making any
correction and include it in your record, to indicate a correction was requested but not
made.
If you disagree and believe that a change should have been made, we will attempt to
resolve the matter with you. If we cannot resolve the matter, we will tell you how to
request a review by the College of Physicians and Surgeons of BC. If you are still
unsatisfied after that review, you may take the matter to the Office of the Information
and Privacy Commissioner for BC (OIPC) .
To request a correction to your personal information, please complete the attached
form. If you need assistance, our Privacy Officer will help you complete the form.
Please see warning and disclaimer on page 2 of the whole BC Physician Privacy Toolkit
Last updated on June 15th, 2009
1
REQUEST FORM TO CORRECT OR AMEND PERSONAL INFORMATION
The information gathered on this form will be used to respond to your request for a
correction to your personal information or the personal information of someone you are
legally entitled to represent.
Whose information do you want to correct?
My own personal information
Another person’s personal information
Please complete the “Patient Information” and “Authorized Representative’s Contact
Information” sections below, and attach proof that you can legally act on behalf of that
individual.
Patient information
Mr / Mrs / Ms (please circle)
Street address: _______________________
Last name: ________________________ City/town: _________________ Prov. ____
First name: ________________________ Postal code: ________ Fax_____________
Personal health number: _____________ Tel: (home) _________ (bus) ____________
Date of birth (dd/mm/yy): _____________ Email address: _______________________
Please describe, in as much detail as you can, the information you want corrected. Be
sure to give the complete patient name that is in the records if it is different from the
name given above. If you need more space, please attach a separate sheet of paper.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What correction or amendment do you want to make and why? Please attach any
documents that support your request.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please see warning and disclaimer on page 2 of the whole BC Physician Privacy Toolkit
Last updated on June 15th, 2009
2
______________________________________________________________________
______________________________________________________________________
__________________________________ ___________________________________
Patient Signature
Date (dd/mm/yy)
Corrections by authorized representative
I am a legally authorized representative of the patient named above and have attached
proof of that representation. I hereby request a correction to the patient’s personal
records on his or her behalf.
Authorized representative’s contact information
Mr / Mrs / Ms (please circle)
Street address: _______________________
Last name: ________________________ City/town: _________________ Prov. _____
First name: ________________________ Postal code: ________ _________________
Telephone (home): __________________Telephone (business) __________________
Fax: _____________________________ Email address: _______________________
__________________________________ ___________________________________
Authorized Representative's Signature
Date (dd/mm/yy)
Please see warning and disclaimer on page 2 of the whole BC Physician Privacy Toolkit
Last updated on June 15th, 2009
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