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.

PART 1: ABOUT YOU

SECTION A:

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

Your Name

Your Address

Sex

Female

Male

Birthdate

Daytime Phone

Cell Phone

SECTION B:

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

Yes

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

Daytime Phone

Address

Why can you request this individual’s information?

No person in any clause above exists or is available

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

TO Date

Notes (optional)

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

PART 3: SIGNATURE

Please sign this form and submit.

Your Signature

Other parent / guardian signature

(required for all minors)

Other signature (Mature Minor)