Access or Correction Request Form

MFIPPA and PHIPA

The personal information on this form is being collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act and will be used for the purpose of responding to your request. Any questions about the collection of this information should be directed to the Manager, CQI and Central Resources at the Kingston, Frontenac and Lennox & Addington Public Health, 221 Portsmouth Avenue, Kingston, Ontario,
613-549-1232, or 1-800-267-7875, ext. 1262

Requesting

Access to General Records

Access to Own Personal Information

Correction of Own Personal Information

Access to Own Personal Health Information

Correction of Own Personal Health Information

Last name

First name

Middle Name

E-mail address

Street address

City or town

Province

Postal Code (no spaces)

Phone number

Alternate phone number (cell phone)

Request details.

If you are requesting to correct a record, please indicate the specific changes you would like made, and attach any necessary supporting documents using the file upload option below. You will be told if the correction will not be made so that you may attach a statement of disagreement to the record.

Please describe in detail the records you would like to access or correct.

Please upload any necessary supporting documents

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Would you like to

Look at original

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By checking this box, I acknowledge I have read, understand, and agree that the information provided in this form is correct.

Yes

I would like to receive e-mail communication from KFL&A Public Health

Yes

No

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Access or Correction Request Form

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