Privacy Concern / Complaint

Client Full Name*
Date of Birth*
MM slash DD slash YYYY
Phone*
I wish to formally complain to the Privacy Officer of Compass in regard to:*
- Access to Personal Health Information
- Disclosure of Personal Health Information
- Use of Personal Health Information
- Other Management of Personal Health Information
My reasons for the complaint are as follows:*
By agreeing to this consent, I hereby confirm that I have legal decision making authority to provide consent on behalf of the above named child/youth (PHIPA, S.23(1)[5]). The consequences of misrepresentation are the responsibility of the undersigned which may also result in termination of services.
I am the*
- Client
- Substitute Decision Maker
Consent*
I agree to the privacy policy.
Date*
MM slash DD slash YYYY