The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment
and Assistance Act and the Employment and Assistance for Persons with Disabilities Act. The collection, use and disclosure of personal information is
subject to the provisions of the Freedom of Information and Protection of Privacy Act. Any questions about this information should be directed to your
local Employment and Assistance Office.
Dear Sir or Madam:
DATE (YYYY MMM DD)
I hereby authorize you to disclose to
Family Maintenance Worker of the Family Maintenance Program, Ministry of Social Development
and Social Innovation or to
Barrister and Solicitor, any and all information contained in my medical records or hospital file,
including diagnosis and prognosis.
OFFICE ADDRESS STAMP
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