Request for Information - Leeds, Grenville and Lanark District Health Unit

Request Type *

Access to General Records
Access to Personal Information/Personal Health Information
Correction to Personal Health Information
Correction to Personal Information

How will you be paying the $5.00 Access to General Records Fee? *

Note: $5.00 application fee must accompany all requests for access to General Records under the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA)

$5.00 eTransfer to [email protected]
$5.00 cash/cheque/debit/credit at our Brockville or Smiths Falls Office
$5.00 cheque made payable to Leeds, Grenville and Lanark District Health Unit mailed to: 458 Laurier Boulevard, Brockville, Ontario K6V 7A3
$5.00 credit card via phone at 1-800-660-5853

Requesting on behalf of *

Self
Someone else

Requesting Personal Health Information

For personal health information, you must demonstrate that you have the right to access this information if requesting for someone else.

Name of Requestor *

First Name Last Name

Position (if applicable)

If you are representing an individual, group, business, or agency please describe

Description of Records Requested *

Contact Information

Preferred Contact Method *

Telephone
Email

Telephone Number (Day)

Telephone Number (Evening)

Email Address *

Personal Health and Information Protection Act (PHIPA)

Personal Information contained on this form is collected pursuant to the Personal Health Information Protection Act, Freedom of Information and Protection of Privacy Act/Municipal Freedom of Information and Protection of Privacy Act and will be used for the purpose of responding to your request.

CAPTCHA

Access to Information Requests

Requesting Personal Health Information

Contact Information

Personal Health and Information Protection Act (PHIPA)