- Report a Privacy Breach
- Your Health Privacy Rights in Ontario
- Requesting Your Personal Health Information
- Correcting Your Personal Health Information
- Consent and Your Personal Health Information
- What You Need to Know About Your Health Card
- Accessing the Personal Health Information of a Deceased Relative
- PHIPA Code of Procedure
Privacy Breach Report Form
For use by health information custodians reporting a theft, loss or unauthorized use or disclosure of personal health information (a privacy breach) to the Information and Privacy Commissioner of Ontario (the IPC) as required under section 12(3) of the Personal Health Information Protection Act, 2004 and Ontario Regulation 329/04 made pursuant to that Act.
Important Note: Do not include any personal health information with this form.
The IPC recognizes that the investigation, containment, and remediation of this privacy breach may not be complete at the time this form is submitted. Please provide as much of the requested information as is presently known.
The IPC may request additional information after reviewing this form.