Request Record of User Activity

To receive a record of who has accessed your personal health information in eChart Manitoba, please fill in the appropriate fields in the form below and submit.

To ensure your submission is accepted, please avoid using any special characters in the form below, such as: ! ‘ # $ % ^ & * ( ) ?, etc.

PART 1: ABOUT YOU

SECTION A:

Please enter the following information about yourself or the individual for whom you are requesting information.

Your Name

First Middle Last

Your Address

Street Address Address Line 2 City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

Sex

Female

Male

Birthdate

DD slash MM slash YYYY

Daytime Phone

Cell Phone

SECTION B:

Do you have a Manitoba Personal Health Identification Number (PHIN)?

Yes

No

Personal Health Identification Number (PHIN)

9-digit number on your Manitoba health card

PHIN Proof

Accepted file types: jpg, gif, png, Max. file size: 10 MB.

SECTION C:

If you are acting on behalf of another individual, complete the following section with your information. If you are requesting the personal health information of a minor, both parents or guardians are required to provide consent. If your child is a mature minor (age 14-17), they will be required to sign and date the form

Information Request Type – Are you…

For yourself

Acting on behalf of another individual?

Requesting the personal health information of a minor?

Requesting the personal health information of a mature minor?

Name

First Last

Daytime Phone

Address

Street Address Address Line 2 City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

Why can you request this individual’s information?

choose one …(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 healthcare decisions on the individual’s behalf;(d) a substitute decision-maker for personal 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) the personal representative if the individual is deceased.(g) If it is reasonable to believe that no person in any clause above exists or is available, the adult person listed first in the following clauses who is readily available and willing to act may exercise the rights of an individual who lacks the capacity to:

No person in any clause above exists or is available

please choose …(a) the individual’s spouse, or common-law partner, with whom the individual cohabits;(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.

If two or more adult persons fall into a category below, the oldest is preferred to act on the individuals’ behalf.

PART 2: ABOUT YOUR REQUEST

Please indicate the date range for which you would like to see who has accessed your personal health information in eChart Manitoba.

Please note: You may be required to pay a fee per printed page.

FROM Date

DD slash MM slash YYYY

TO Date

DD slash MM slash YYYY

Notes (optional)

PART 3: SIGNATURE

Please sign this form and submit.

Your Signature

Other parent / guardian signature

(required for all minors)

Other signature (Mature Minor)