Manitoba Authorization for Release of Medical Information Form
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I am aware that The College of Physicians and Surgeons of Manitoba (“the College’) is
reviewing concerns about the care provided to me and that the College is collecting my personal
health information for the purpose of its review.

You are hereby authorized to furnish and release to the College, or its representative, any and all
information which it requests for the purpose of its review relative to my past and present health,
including my mental, physical or other condition, my health history, any prescriptions or any
other treatment provided to me and the results of any diagnostic procedures,.

I am aware that this authorization may be used by the College for release of such personal health
information as physician office records/charts, hospital records/charts, prescribing information,
and billing records.

This authorization shall continue until revoked by me, in writing. A photostatic copy of this
authorization shall serve in its