Medical record

To get a copy of a document in your medical record, you can send a written request that includes the following information:

  • Full name
  • Date of birth
  • Full name of the mother
  • Nature and dates of the requested information
  • Full return address
  • Signature and date of the request

Or you can print and fill out the Démarre le chargement du fichierRequest form (in French).

Precisions

  • You must send your request or sign it on site at the concerned facility (e.g.:  Hôpital Le Royer, CLSC Lionel-Charest, Hôpital de Sept-Îles).
  • No request can be processed by email.
  • Ne medical information can be transmitted on the phone.
  • No document can be faxed, except in an emergency situation.
  • Fees may be charged in accordance with existing regulations.
  • The institution shall give the user access to his record as soon as posible (ARHSSS, article 26).

For more information, please contact the staff of the Medical records department of the concerned facility.

Fees

Fees may be charged for the reproduction of documents in the record. However, no fee will be charged for the first 20 pages. Fees will be charged for additional pages in accordance with the applicable rates. Should fees be charged, we will contact you by mail to tell you the amount you will have to pay to get the requested documents. These fees are payable in advance.

Waiting time

Requests from users are generally answered within a few weeks. The Act respecting Access to documents held by public bodies and the Protection of personal information (article 47) provides that the requests received must be answered within 20 calendar days.

References

Medical imaging: You are referred to this service when you want to get x-ray films or their reproduction.
Directeur de l'État civil: You are referred to this government body when you want to get official documents, such as the act or certificate of birth or death.

Access

All information contained in the medical record is confidential. No one can access it without authorization from the user or their legal representative. Consent is required to transmit information from a record, except in cases provided for by law (for example, CNESST, SAAQ, IVAQ, RAMQ).

If you are the parent or legal guardian of a child under the age of 14, you can sign the authorization. However, if your child is over the age of 14, they must sign the consent themselves (note that there are certain exceptions, for example, in case of incapacity).

In certain situations, evidence may be requested in order to support your request: birth certificate, adoption certificate, proof of legal guardianship, will, etc. If this is the case, you will be contacted.

If a user wants to get documents, but is incapable of signing the consent form, please write the medical reason for this incapacity and support your request with the signature of two witnesses.

Access to the record of a living user

In order to have access to the information in your medical record, you must send a written request, signed and recently dated. You can write your request yourself or use the following standard form:
Démarre le chargement du fichierAuthorization for providing access to information on file (in French only)

Access to the record of a deceased user

The record of a deceased person remains confidential, even after their death. The Act respecting health services and social services provides certain terms for access to the record of a deceased user.

Anyone who wants to have access to the medical record of a deceased user must clearly specify their needs and provide a proof of their title using a relevant document in order to exercise their rights in such capacity (will, insurance policy, etc.). Moreover, if the user did not decease within the establishment, a death certificate will be requested.

Your request must contain the following information:

  • Full name of the deceased
  • Date of birth of the deceased
  • Date of death
  • Your full name
  • The requested documents
  • Address of the recipient
  • Signature

Legislation

The spouse, ascendants or descendants are entitled to know the cause of death of the user. The following documents will be given:

  • A photocopy of the death certificate (SP-3), which contains the identification of the deceased user, the date and time of death, the cause of death, and the signature of the physician who attested the death.

And/or

  • The attestation of death, which contains the date and time of death and the signature of the physician who attested the death.

Persons related by blood to a deceased user may know the genetic or hereditary diseases. However, they must specify the exact disease to look for in the record.

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