Provincial Laboratory Medicine Services Out-of-Province & Out-of-Country Laboratory or Genetic Test Funding Request
Consent for release of information
CONSENT FOR RELEASE OF INFORMATION
Your physician has ordered a Laboratory Test (“Test”) that is only available at a testing facility outside of British Columbia (“Testing Facility”). Funding approvals for out-of-province and out-of-country laboratory services for British Columbia residents is delegated by the BC Ministry of Health to the Provincial Laboratory Medicine Services (PLMS) of the Provincial Health Services Authority.
In order for the Test to be completed and to have the results reported back to us and your physician, your sample and your personal information will be provided to the Testing Facility. The personal information that your physician has provided to us or that is provided to or accessible by the Testing Facility includes:
• Your name
• Date of birth
• Personal Health Number (PHN)
• Brief health history relevant to the Test
• Your Test results.
We collect your personal information under the authority of the British Columbia Freedom of Information and Protection of Privacy Act (FIPPA), and we store and maintain it in Canada on an online platform. Your personal information may be used or disclosed for the following reasons:
• To receive and respond to an application for a Test from your physician;
• To confirm your eligibility for funding for the Test;
• To make decisions about your application for a Test;
• To request and receive your Test results from the Testing Facility;
• To communicate with your health care providers about your Test;
• To communicate with Health Insurance BC to fund your Test and make required payments to the Testing Facility; and
• To communicate with your physician or with the Ministry of Health if there are any complaints or problems with the Test or the Testing Facility.
We may also use the personal information that we obtain from testing to assess, evaluate and improve our program and services. We may report the results of this analysis to the Ministry of Health in aggregated form (i.e., with you name and other personal identifiers removed).
You should also know that when we provide your information to the Testing Facility it will be collected, used, processed and stored by the Testing Facility in the country where it is located. This means that it will be subject to the laws of that country and will potentially be subject to disclosure demands under those laws. You acknowledge and agree that we have no responsibility or liability for the Testing Facility’s handling of your personal information. We are required by FIPPA to obtain your written consent for any access to or storage of your personal information outside of Canada, including when we transmit your personal information to the Testing Facility.
By signing this consent, you are consenting to the collection, use and disclosure of your personal information and sample as described above (page 1). Providing this consent is voluntary. If you do not wish to provide your consent, you should discuss with your physician the available alternatives to the Test
Person giving consent
All fields must be completed legibly (patient demographics label is acceptable).
* Patient First Name:
* Patient Last Name:
* Date of Birth (MM-DD-YYYY):
* Personal Health Number (PHN):
* Signature of Person Giving Consent (Full Name):
* Relationship to Patient:
Select...
Patient
Parent
Representative
* Date (MM-DD-YYYY):
If you have any questions regarding this consent or the processing of your personal information, you may contact the Chief Medical Laboratory Officer, PLMS, at 604-714-2829. You may also wish to review our privacy policy which is available at www.phsa.ca/privacy
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