Health Information Services Policies & Forms
General (also access HIS or Privacy and Access)
| Policy # | Title | Rationale | Date | Summary | Link |
|---|---|---|---|---|---|
| ORG.1411.PL.502.SD.02 | Access Disclosure Release of Personal Health Information Fee Schedule | To revise for new WCB rate effective January 1, 2025. | Dec 29, 2025 | ||
| ORG.1411.PL.502.FORM.01.F | Consent to Disclose French PRINT ONLY | Oct 6, 2025 | |||
| ORG.1411.PL.101.FORM.01 | Request to Access Personal Health Information Form PRINT ONLY | Oct 6, 2025 | |||
| ORG.1411.PL.101.FORM.01.F | Request to Access Personal Health Information Form French PRINT ONLY | Oct 6, 2025 | |||
| ORG.1411.PL.502.FORM.01 | Consent to Disclose PRINT ONLY | Oct 6, 2025 | |||
| ORG.1410.PL.001.FORM.03 | Client Chart Health Record Order Audit Tool PCH and Transitional Care Centres | Apr 7, 2025 | |||
| ORG.1410.PL.202.SD.01 | Retention Schedule for Non Client Records | to reflect changes in The Limitations Act | Feb 24, 2025 | ||
| ORG.1410.PL.303.FORM.01 | Notice of Lost Destroyed Incomplete Information Form | Feb 24, 2025 | |||
| ORG.1410.PL.202 | Retention of Non Client Records | Feb 24, 2025 | |||
| ORG.1410.PL.202.SD.02 | Change History Table Retention Schedule for Non Client Records | to track revisions and why | Feb 24, 2025 | ||
| ORG.1411.SG.003 | Secondary Use of Personal Health Information | Dec 16, 2024 | |||
| ORG.1411.PL.508 | Disclosure of Information to Affiliated Foundations | Dec 16, 2024 | |||
| ORG.1410.PL.002.FORM.03 | Reinstatement of Privileges | changing VP Medical to Regional Lead-Medical Services & CMO | Dec 16, 2024 | ||
| ORG.1410.PL.002.FORM.02 | Notice of Suspension to Inform Health Information Services Nursing Units | changing VP Medical to Regional Lead-Medical Services & CMO | Dec 16, 2024 | ||
| ORG.1410.PL.002.FORM.01 | Notice of Suspension To Physician | changing VP Medical to Regional Lead-Medical Services & CMO | Dec 16, 2024 | ||
| ORG.1410.PL.003 | Management of Incomplete Health Records | Renamed/revised policy to address alternatives and timelines to managing outstanding incomplete health record in prolonged situations not just for medical Staff departure but also noncompliance in accordance with ORG.1410.PL.003 Health Record Completion by Medical Staff | Dec 16, 2024 | ||
| ORG.1410.PL.002 | Health Record Completion by Medical Staff | Dec 16, 2024 | |||
| ORG.1410.PL.003.SD.01 | Incomplete Health Record Notice | Dec 16, 2024 | |||
| ORG.1410.PL.002.SD.01 | Completion of Health Records Standards | Completion of Health Records Standards to align with Provincial Medical Council Leadership endorsement of no longer requiring face sheet completion when thorough discharge summaries and OR reports are completed | Dec 16, 2024 | ||
| ORG.1410.PL.201.SD.01 | Retention Schedule of Personal Health Information | revision of retention period for paper index cards from permanent to 20 years after the implementation of an electronic ADT. the paper index cards will not serve a business purpose after the minimum retention period. | Nov 21, 2024 | ||
| ORG.1410.PL.201.FORM.01 | Record of Destruction Log | Oct 10, 2024 | |||
| ORG.1410.PL.201 | Retention and Destruction of Personal Health Information | Removed retention period for blood and blood products - to follow minimum retention period of discharges - therefore step to purge record for same was deleted. removed statement that records may be kept longer if space available. | Oct 10, 2024 | ||
| ORG.1411.SG.002 | Disclosure of Personal Health Information for Review by Health Care Professionals and or a Professional Regulatory Body | To provide direction when a request is received by a Health Care Professional's legal counsel for the disclosure of personal health information. | Oct 10, 2024 | ||
| ORG.1411.PL.002.SD.01 | Request for Access Response Coordination Process Flow Chart | Policy revised to reflect amendments to FIPPA. Procedures included in ORG.1411.PR.001 & name changed to reflect same. Supporting document updated and name changed from FIPPA Process Overview April 2015 | Jul 8, 2024 | ||
| ORG.1410.PL.008 | Control of Health Records | To define guidelines for the removal and return of health records to Health Information Services. Some sites face challenges with records returning in a timely manner. | Jul 8, 2024 | ||
| ORG.1411.PR.001 | Request for Access Response Coordination Process under The Freedom of Information and Protection of Privacy Act | Created procedure that aligns with amendments to FIPPA. To provide a step by step process for responding to requests to access records under FIPPA. | Jul 8, 2024 | ||
| ORG.1411.PR.002 | Third Party Consultation Process under The Freedom of Information and Protection of Privacy Act | To further provide direction related to the Third Party consultative process under FIPPA. | Jul 8, 2024 | ||
| ORG.1411.PL.002.SD.02 | Third Party Consult Flow Chart | Policy revised to reflect amendments to FIPPA. Procedures included in ORG.1411.PR.001 & name changed to reflect same. Supporting document updated and name changed from FIPPA Process Overview April 2015. | Jul 8, 2024 | ||
| ORG.1411.PL.002.FORM.01 | Application for Access Form | Policy revised to reflect amendments to FIPPA. Procedures included in ORG.1411.PR.001 & name changed to reflect same. Supporting document updated and name changed from FIPPA Process Overview April 2015. | Jul 8, 2024 | ||
| ORG.1411.PR.001.FORM.01 | The Freedom Information and Protection of Privacy Act Communication Template | Created procedure that aligns with amendments to FIPPA. To provide a step by step process for responding to requests to access records under FIPPA. | Jul 8, 2024 | ||
| ORG.1411.PL.004 | Correction of Personal Information Under The Freedom of Information and Protection of Privacy Act | Revised to reflect amendments to FIPPA and new SH-SS format. | Jul 8, 2024 | ||
| ORG.1411.PL.002 | Access to Information and Processing of Requests under FIPPA | Policy revised to reflect amendments to FIPPA. Procedures included in ORG.1411.PR.001 & name changed to reflect same. Supporting document updated and name changed from FIPPA Process Overview April 2015. | Jul 8, 2024 | ||
| ORG.1411.PL.003 | Administration Responsibilities Under The Freedom of Information and Protection of Privacy Act | Update to reflect amendments to FIPPA. New format. | Jul 8, 2024 | ||
| ORG.1410.PR.001.FORM.02 | Secured Health Records Log | Feb 1, 2024 | |||
| ORG.1410.PR.001 | Securing Health Records | Feb 1, 2024 | |||
| ORG.1410.PR.001.FORM.01 | Health Record Safekeeping Control Report | Feb 1, 2024 | |||
| ORG.1410.PL.101.SD.01 | Standard Operating Procedure for Recording and Reporting Alternate Level of Care ALC | Added as a supporting document within the ALC Policy- Alternate Level of Care (ALC) to provide support to the health care team in implementing a process change - using the completed ALC designation form to also report ALC in the ADT EPR | Jan 29, 2024 | ||
| ORG.1410.PL.101.FORM.01 | Alternate Level of Care Designation Record | Standard Operating Procedure Org.1410.PL.101.FORM.02 has been added as a supporting document within the ALC Policy- Alternate Level of Care (ALC) to provide support to the health care team in implementing a process change - using the completed ALC designation form to also report ALC in the ADT EPR | Jan 29, 2024 | ||
| ORG.1410.PL.101 | Alternate Level of Care | Updated provincial ALC designation form ORG.1410.PL.101.FORM.01, which is a supporting document within the policy. Standard Operating Procedure Org.1410.PL.101.FORM.02 has been added as a supporting document to provide support to the health care team in implementing a process change - using the completed ALC designation form to also report ALC in the ADT EPR | Jan 29, 2024 | ||
| ORG.1411.PL.507.SD.01 | Texting on Smart Phones in the Workplace Frequently Asked Questions FAQ | Provide direction to SH-SS staff when using texting as a method of communicating with clients, natural supports and other staff. | Jan 15, 2024 | ||
| ORG.1411.PL.507 | Texting with Clients Natural Supports and other Staff | Provide direction to SH-SS staff when using texting as a method of communicating with clients, natural supports and other staff. | Jan 15, 2024 | ||
| ORG.1410.SG.001 | Encrypting Records using 7 Zip File Manager | Jan 15, 2024 | |||
| ORG.1411.SG.002.SD.01 | Disclosure of PHI for Review by HCP andor a Professional Regulatory Body Letter Template | Jan 15, 2024 | |||
| ORG.1411.PL.404 | Security and Storage of Confidential Information including Transportation | To align with Digital Shared Services around the use of USB storage devices, specifically restricting the use of network connected devices to only accept encrypted USB storage devices. | Dec 29, 2023 | ||
| ORG.1411.PL.502.SD.01 | Personal Health Information Act PHIA Definitions | Included definitions for alternate decision maker and health | Dec 29, 2023 | ||
| ORG.1411.PL.001.SD.01 | FIPPA Definitions | Dec 29, 2023 | |||
| ORG.1411.PL.001 | Annual Reporting Under The Freedom of Information and Protection of Privacy Act FIPPA | Dec 29, 2023 | |||
| ORG.1410.PL.551 | Staff Witness to Legal Documents | Apr 13, 2023 | |||
| ORG 1410.PL.001.SD.02 | Client Chart Health Record Order Home Care Nursing | Feb 16, 2023 | |||
| ORG.1410.PL.302 | Health Record Management in the Event of an Evacuation | Jan 13, 2023 | |||
| ORG.1411.PL.404.FORM.02 | Tracking Transport Confidential Information Records for Appointments Form | Jan 11, 2023 | |||
| ORG.1411.PL.404.FORM.01 | Tracking of Confidential Information Worksheet | Jan 11, 2023 | |||
| ORG.1410.PL.005.SD.01 | Thinning of Documents from Client Charts in Clinical Area Program Guideline Acute Care | Oct 19, 2022 | |||
| ORG.1410.PL.005.SD.02 | Thinning of Documents from Client Charts in Clinical Area Program Guideline Home Care Nursing | Oct 19, 2022 | |||
| ORG.1410.PL.005.SD.03 | Thinning of Documents from Client Charts in Clinical Area Program Guideline PCH and Transitional Care Centres | Oct 19, 2022 | |||
| ORG.1410.PL.005 | Thinning of Documents from Client Charts in Clinical Areas Programs | Oct 19, 2022 | |||
| ORG.1410.PL.005.FORM.01 | Thinning of Documents From Client Charts Tracking | Oct 19, 2022 | |||
| ORG 1410.PL.001.SD.04 | Client Chart Health Record Order PCH and Transitional Care Centres | Oct 19, 2022 | |||
| ORG.1410.PL.001 | Client Chart Health Record Order | Oct 19, 2022 | |||
| ORG.1410.PL.001.SD.01 | Client Chart Health Record Order Acute Care | Oct 19, 2022 | |||
| ORG.1410.PL.001.FORM.01 | Client Chart Health Record Order Audit Tool Acute Care | Oct 19, 2022 | |||
| ORG.1410.PL.001.FORM.02 | Client Chart Health Record Order Audit Tool Home Care Nursing | Oct 19, 2022 | |||
| ORG.1411.PL.101.FORM.06.F | Request for Additional Information Template – French | Oct 3, 2022 | |||
| ORG.1411.PL.101.FORM.01.F | Request to Access Personal Health Information – French | Oct 3, 2022 | |||
| ORG.1411.PL.101.FORM.03.F | Refusing a Request For Access – French | Oct 3, 2022 | |||
| ORG.1411.PL.101.FORM.07.F | Notification of Abandoned Request Template – French | Oct 3, 2022 | |||
| ORG.1411.PL.101.FORM.05.F | Estimate of Fees for Access to Personal Health Information Template FR | Oct 3, 2022 | |||
| ORG.1411.PL.101 | Access to Personal Health Information | Oct 3, 2022 | |||
| ORG.1411.PL.101.FORM.04 | Record Does Not Exist or Cannot Be Located Template | Sep 29, 2022 | |||
| ORG.1411.PL.203 | Reporting and Investigating Privacy Breaches and Complaints | Jul 13, 2022 | |||
| ORG.1411.PL.203.FORM.02 | Reporting and Investigating Privacy Breaches and Complaints Fact finding Interview Guide | Jul 13, 2022 | |||
| ORG.1411.PL.203.FORM.01 | Privacy Incident Report | Jul 13, 2022 | |||
| ORG.1411.PL.101.FORM.01 | Request to Access Personal Health Information | Mar 3, 2022 | |||
| ORG.1411.PL.101.FORM.06 | Request for Additional Infomation Template | Jan 28, 2022 | |||
| ORG.1411.PL.101.FORM.07 | Notification of Abandoned Request Template | Jan 28, 2022 | |||
| ORG.1411.PL.101.FORM.05 | Estimate of Fees for Access to Personal Health Information Template | Jan 28, 2022 | |||
| ORG.1411.PL.104 | Correction of Personal Health Information | Jan 28, 2022 | |||
| ORG.1410.PL.001.SD.03 | Client Chart Health Record Order Home Care Case Coordinator | Jan 21, 2022 | |||
| ORG.1411.PL.502 | Use and Disclosure of Personal Health Information | Dec 20, 2021 | |||
| ORG.1411.PL.503.SD.03 | Video Surveillance Notification | Nov 17, 2021 | |||
| ORG.1411.PL.503.SD.02 | Respect Privacy Poster | Nov 17, 2021 | |||
| ORG.1411.PL.503.SD.01 | Respect Privacy Poster Long Term Care | Nov 17, 2021 | |||
| ORG.1411.PL.503 | Audio Video and Photographic Recording including Surveillance | Nov 17, 2021 | |||
| ORG.1411.PL.101.FORM.03 | Refusing a Request For Access | Aug 27, 2021 | |||
| ORG. 1411.PL.006 | Preparing Fee Estimates under the Freedom of Information and Protection of Privacy Act FIPPA | Jan 29, 2021 | |||
| ORG.1410.PL.402.SD.05 | Iron Mountain Permanent Withdrawal and Destruction | Jan 21, 2021 | |||
| ORG.1410.PL.402 | Off Site Storage of Records | Jan 18, 2021 | |||
| ORG.1410.PL.402.FORM.01 | Iron Mountain Request to Add New Division | Jan 18, 2021 | |||
| ORG.1410.PL.402.SD.01 | Iron Mountain Requesting Reports | Jan 18, 2021 | |||
| ORG.1410.PL.402.SD.04 | Iron Mountain Searching in the Records Centre | Jan 18, 2021 | |||
| ORG.1410.PL.402.FORM.03 | Iron Mountain Access Form Request to Add or Delete User | Jan 18, 2021 | |||
| ORG.1410.PL.402.SD.02 | Iron Mountain Adding Boxes and Files | Jan 18, 2021 | |||
| ORG.1410.PL.402.SD.03 | Iron Mountain Creating a Pickup Order | Jan 18, 2021 | |||
| ORG.1410.PL.402.FORM.02 | Iron Mountain Request to Add New Department | Jan 18, 2021 | |||
| ORG.1411.SG.001.SD.01 | Email Acknowledgment and Agreement | Sep 4, 2020 | |||
| ORG.1411.SG.001 | Emailing Confidential Information | Sep 4, 2020 | |||
| ORG.1411.PL.505.FORM.01 | Disclosure of Personal Health Information to Police Without Consent Form | Feb 4, 2020 | |||
| ORG.1411.PL.505 | Disclosure of Personal Health Information to Police | Feb 4, 2020 | |||
| ORG.1411.PL.502.FORM.03 | Record of Access Disclosure Release of Personal Health Information | Oct 29, 2019 | |||
| ORG.1411.PL.502.FORM.01 | Consent to Disclose Personal Health Information | Oct 29, 2019 | |||
| ORG.1411.PL.502.FORM.01.F | Consent to Disclose Personal Health Information Form – French | Oct 29, 2019 | |||
| ORG.1411.PL.502.FORM.02 | Consent to Use Personal Health Information Form | Oct 29, 2019 | |||
| ORG.1411.PL.502.FORM.02.F | Consent to Use Personal Health Information Form – French | Oct 29, 2019 | |||
| ORG.1411.PL.411.FORM.01 | The Protecting Children Information Sharing Act Information Request | Feb 5, 2019 | |||
| ORG.1411.PL.411.SD.01 | The Protecting Children Information Sharing Act Decision Making Tool | Feb 5, 2019 | |||
| ORG.1411.PL.411.SD.02 | Question and Answer Guide for The Protection of Children Information Sharing Act | Feb 5, 2019 | |||
| ORG.1411.PL.411 | Information and Sharing under The Protecting Children Information Sharing Act PCISA | Feb 5, 2019 | |||
| ORG.1411.PL.201.SD.01 | PHIA Self Learning Package General | Nov 8, 2018 | |||
| ORG.1410.PL.550.SD.01 | Data Report Naming Convention | Nov 5, 2018 | |||
| ORG.1410.PL.550.FORM.01 | Health Information Data Request Form | Oct 29, 2018 | |||
| ORG.1410.PL.550 | Health Information Data Request Process | Oct 29, 2018 | |||
| ORG.1411.PL.201 | Confidentiality of Personal Health Information | Sep 21, 2017 | |||
| ORG.1410.PL.302.FORM.02 | Transfer Summary for Evacuation | Feb 1, 2017 | |||
| ORG.1410.PL.302.FORM.01 | Transferring of Health Records for Evacuation Worksheet | Feb 1, 2017 | |||
| ORG.1411.PL.505.SD.02 | Statement Request from Police for PHI Flowchart | Feb 1, 2017 | |||
| ORG.1411.PL.505.SD.03 | Request for Personal Health Information from Police MPI WCB Chief Medical Examiners office | Feb 1, 2017 | |||
| ORG.1411.PL.104.FORM.01 | Request to Correct Personal Health Information | Feb 1, 2017 | |||
| ORG.1411.PL.104.FORM.01.F | Request to Correct Personal Health Information – French | Feb 1, 2017 | |||
| ORG.1411.PL.502.FORM.05 | Record of Disclosure of Personal Health Information Community | Feb 1, 2017 | |||
| ORG.1411.PL.502.FORM.04 | Record of Access Disclosure Release of Personal Health Information Community | Feb 1, 2017 | |||
| ORG.1410.PL.202.FORM.01 | Record of Destruction Log Non Client | Feb 1, 2017 | |||
| ORG.1410.PL.302.SD.01 | Physician Responsibilities Client Evacuation | Feb 1, 2017 | |||
| ORG.1410.PL.303.FORM.03 | Location of Records Log | Feb 1, 2017 | |||
| ORG.1411.PL.201.FORM.02 | Information and Agreement for Persons Associated with SH-SS | Feb 1, 2017 | |||
| ORG.1411.PL.101.FORM.02 | Granting Request For Access Form | Feb 1, 2017 | |||
| ORG.1411.505.SD.01 | Emergency Demand for Records Sample | Feb 1, 2017 | |||
| ORG.1411.PL.505.FORM.02 | Disclosure of Personal Health Information to Police With Consent Form | Feb 1, 2017 | |||
| ORG.1410.PL.303.FORM.02 | Damaged Records for Destruction Log | Feb 1, 2017 | |||
| ORG.1411.PL.201.FORM.01 | Declaration of Confidentiality | Feb 1, 2017 | |||
| ORG.1410.PL.303 | Disaster Management and Recovery of Paper Based Records | Feb 1, 2017 | |||
| ORG.1411.PL.404.FORM.03 | Confidential Information Label | Feb 1, 2017 | |||
| ORG.1411.PL.201.FORM.03 | Confidentiality Agreement for Vendors | Feb 1, 2017 | |||
| ORG.1411.PL.102 | Access Disclosure and Correction to the Clinical Record under The Mental Health Act | Feb 1, 2017 | |||
| ORG.1411.PL.201.FORM.04 | Agreement for Persons Conducting QI or Program Evaluation | Feb 1, 2017 | |||
| ORG.1410.PL.004 | Health Records of Adopted Children | Jan 23, 2017 | |||
| ORG.1411.PL.504 | Disclosure of Personal Health Information Requested for Legal Proceedings | Jan 23, 2017 | |||
| ORG.1410.PL.002.SD.04 | Physician Deficiency Notice | Jan 19, 2017 | |||
| ORG.1410.PL.002.SD.02 | Physician Deficiency Slip | Jan 19, 2017 | |||
| ORG.1410.PL.002.SD.03 | Physician Deficiency List 28 Days | Jan 13, 2017 | |||
| ORG.1411.PL.301.FORM.02 | Privacy Impact Assessment Addendum | Jan 12, 2017 | |||
| ORG.1411.PL.301.SD.01 | Privacy Impact Assessment Guide | Jan 12, 2017 | |||
| ORG.1411.PL.301.FORM.01 | Privacy Impact Assessment Tool | Jan 12, 2017 | |||
| ORG.1411.PL.301 | Completion of Privacy Impact Assessment PIA | Jan 12, 2017 | |||
| ORG.1411.PL.302 | Privacy Requirements for Electronic Information Systems Databases | Jan 10, 2017 | |||
| ORG.1411.PL.302.SD.01 | Privacy Requirements for Electronic Information Systems Flowchart | Jan 10, 2017 | |||
| ORG.1411.PL.405 | Audit of Security Safeguards | Jan 10, 2017 | |||
| ORG.1410.PL.007 | Management of Electronic Health Information System Printouts | Jan 9, 2017 | |||
| ORG.1411.PL.501 | Collection of Personal Health Information | Jan 9, 2017 | |||
| ORG.1411.PL.407 | Transmission of Personal Health Information Via Facsimile Fax | Mar 14, 2016 | |||
| ORG.1411.PL.407.SD.01 | Transmission of Personal Health Information via Fax Checklist | Mar 14, 2016 | |||
| ORG.1410.PL.105 | Standard Date and Time | Jan 13, 2016 | |||
| ORG.1410.PL.203 | Disposal of Personal Health Information | Jan 13, 2016 | |||
| ORG.1411.PL.007 | Privacy of Personal Information under The Freedom of Information and Protection of Privacy Act FIPPA | Dec 14, 2015 | |||
| ORG.1411.PL.005 | Powers and Duties of The Ombudsman Under The Freedom of Information and Protection of Privacy Act FIPPA | Dec 14, 2015 | |||
| ORG.1411.PL.506 | Disclosure of Personal Health Information for Health Research | Apr 8, 2015 | |||
| Org.1410.PL.301.SD.01 | Poster Notification of reason for verification | Mar 11, 2015 | |||
| ORG.1410.PL.301 | Client Identification | Mar 11, 2015 |