Birth parents and other birth relatives in Ontario use this application to ask the Custodian of Adoption Information to locate an adopted person, or their descendants, so that medical information can be obtained or shared. It applies when that information would significantly increase the likelihood of diagnosing or treating a severe mental or physical illness. A health care professional's questionnaire supplies the medical justification.
The birth family applicant completes Parts A to C and signs the statement in Part E. A physician or other regulated health care professional completes the Part D questionnaire after the patient signs its consent to disclose health information.
Download the current version from the source each time; forms change without notice.
Birth Family Member's Application to Request a Severe Medical Search
Demande de recherche présentée par un membre de la famille généalogique en raison de graves problèmes de santé
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Part D must be completed by a physician or other regulated health care professional: a CPSO member, a Fellow of the Royal College (FRCP or FRCS), a registered psychologist, a nurse in the extended category, or another regulated professional who describes their designation.
Yes. The French edition, 3089F, is titled Demande de recherche présentée par un membre de la famille généalogique en raison de graves problèmes de santé. The ministry's forms site also posts Word and accessible HTML versions of the form and its completion guide.
A description of the patient's health condition, including the presenting problem, diagnosis and prognosis, and supporting evidence if prevention is a factor. You also explain whether the information sought is essential to diagnosis or treatment, then sign a statement certifying the information is true.