MEDICAL RECORD TRANSFER

I Want to Receive my Medical Record

ATTENTION: The information collected enables the Clinique d'ophtalmologie Bellevue to send you the requested medical record. It is your responsibility to provide accurate, complete, and up-to-date information. We invite you to double-check your details before submitting the form.

Confidentiality: To protect the confidentiality of your medical record, the Clinique d'ophtalmologie Bellevue will verify your identity before transmitting any medical information. Additional information or documents may be requested when necessary to confirm your identity or your status as an authorized representative.

Processing Time: Your request will be processed diligently in accordance with applicable legal provisions. The maximum time limit under the Act respecting health and social services information is generally 30 days following receipt of the request. Please ideally expect an automatic acknowledgment of receipt indicating that the request has been received and that identity verification may be required.

Need help with the form? You can contact the medical records department at (514) 256-0007.

Demande de dossier - EN

PERSONAL INFORMATION

AUTHORIZATION FOR TRANSMISSION OF MEDICAL RECORD

LEGAL REPRESENTATIVE INFORMATIONL

A document proving your authority to act on behalf of the user may be required before medical information can be disclosed.

For the care or services relating to the following period:

I expressly request that my medical record be sent to the email address indicated. I understand that regular email may present confidentiality risks and I accept this method of transmission despite these risks.