Additional information and FAQ

Who can obtain the medical information contained in a user’s medical record?

According to the AHSSS, “the record of a user is confidential and no person may have access to it except with the consent of the user or the person qualified to give consent on his behalf” (with certain exceptions).  
Generally, persons 14 years of age or over are entitled to have access to their medical records.

Other persons, such as the professionals and members of the personnel who are treating you in the CSSS des Collines can have access to your record, if the Act provides for this or if you have authorized them to have access.

In addition, if you have initiated a claim related to your physical or mental health, the other party can apply for access to the  relevant information contained in your medical record.

Exceptions
The institution can refuse to grant you access to your record in certain specific circumstances provided for in the Act.

We  can deny you access to your medical record, if the attending physician considers that “communication of the record or any part thereof would likely be seriously prejudicial to the user’s health. In that case, the institution, on the recommendation of the physician, shall determine the time at which the record (or the part thereof to which access has been denied) can be communicated to the user, and notify him thereof.

No user is entitled to be informed of the existence or be given communication of information concerning him furnished by a third person which is contained in his record, where knowledge of the existence or the communication thereof would make it possible to identify the third person, unless that person has agreed in writing to the disclosure of the information and of its source to the user.

The first paragraph does not apply where the information was furnished by a health or social services professional or by an employee of an institution in the performance of his duties. For the purposes of this paragraph, trainees, including medical residents, shall be regarded as health or social services professionals.”

Can a user consult his/her medical record?
For an on-site consultation, the user should call the Medical Records Department to make an appointment during office hours. During this consultation, the user will be assisted by a medical archivist.

How can I obtain an attestation of a visit or a birth certificate?
To obtain an attestation of a visit, you should simply follow the procedure outlined above. Transcription fees of $15 will apply for this document and must be paid before or at the time of collection of the document.

How can I obtain radiology films or a reproduction of these films?
You should contact the medical imaging department directly.

Who should fill out my insurance form?
Your  medical insurance and return to work forms can be filled out and signed only by your attending physician. Consequently, you should ask the physician or his secretary about the procedure to be followed. In the case of a form to be filled out following a visit to the emergency, the secretarial service of the emergency physicians is located in the hospital.

On the death of a user, who can have access to his record?
“The heirs, legatees by particular title and legal representatives of a deceased user are entitled to be given communication of information contained in his record to the extent that such communication is necessary for the exercise of their rights in such capacity. The same applies to the person entitled to the payment of a benefit under an insurance policy on the life of the user or under a pension plan of the user.

The spouse, ascendants or direct descendants of a deceased user are entitled to be given communication of information relating to the cause of death of the user, unless the deceased user entered in writing in his record his refusal to grant such right of access.

Notwithstanding the second paragraph, persons related by blood to a deceased user may be given communication of information contained in his record to the extent that such communication is necessary to verify the existence of a genetic or hereditary disease.

The holder of parental authority is entitled to be given communication of the information contained in the record of a user under 14 years of age even if the user is deceased. However, that right of access does not extend to information of a psychosocial nature.”

When applying for access to information contained in the record of a deceased user, you must clearly justify your need for this information and provide all the supporting documents required (e.g. will and certificate of a will search, insurance policy, birth certificate…)

How can I obtain an autopsy report/coroner’s report?
For a coroner’s report, you must apply to the Bureau du coroner. Otherwise, you should apply to the institution that carried out the autopsy.