Your information

Last name (required)

First name (required)

Middle initial(s)

Preferred name

Address

Unit

City

Province

Postal code

If you consent to the IPC contacting you by phone including leaving a voicemail message, please provide your phone number

If you wish to communicate with the IPC by email, please provide your email address (required)

Please note that email communication is optional and the security of email communication cannot be guaranteed.

Are you (check one):

Filing a privacy complaint about your own personal health informationThe substitute decision-maker (such as a parent or guardian) for someone who is filing a privacy complaint about their personal health information

Substitute decision-maker information
Skip this section if you are not a substitute decision-maker.

If you are a substitute decision-maker (such as a parent or guardian) making a complaint on behalf of someone else, please describe your role and explain your relationship. It may be necessary to provide documentation to prove you are authorized to act for the individual. Please attach this documentation if you have it at the end of this form.

Representative Information
Skip this section if you do not have a representative.

You may represent yourself in a complaint to the IPC, or have someone else (such as a lawyer or another person) represent you.

If someone is representing you, and you authorize that person to act on your behalf, and you consent to the IPC to contacting them (including through email) and exchanging information about this complaint, please fill out the contact information below.

Representative is a (check one):
LawyerOther person

Please provide your representative’s contact information

Last name

First name

Middle initial(s)

Preferred name

Address

Unit

City

Province

Postal code

Phone number

Email address

Information about health information custodian your complaint relates to

Name of health information custodian your complaint relates to

Name of contact person at the health information custodian, if applicable

Address

Unit

City

Province

Postal code

Phone number

Email address

File number for your complaint (if applicable)

Sharing your information

We would like to share your complaint with the health information custodian you have complained about, so the health information custodian understands the reasons for your complaint and the IPC can process your complaint.

By filing this complaint, you consent to share your name, this complaint form, and all attachments provided with this complaint form to all of the parties to this complaint (including the health information custodian).

If you do not consent to share your complaint information, please explain why below. We will consider whether we can properly address your complaint without sharing this information.

We may need additional personal health information to process your complaint. Do you consent to the IPC looking at or asking for the personal health information we need to process your complaint? (required)
YESNO

Details of your complaint

Please select all the boxes that explain why you are making the complaint:
The health information custodian the complaint relates to has inappropriately collected, used and/or disclosed (shared) my personal health informationOther – please explain:

Please provide a detailed description of your complaint. Your description should include the what, when, who, how, where and why of what happened. If you need more space, please attach as many pages as necessary at the end of this form.

Have you communicated with the health information custodian about your complaint? If so, please explain.

Resolution of your complaint

Do you have a suggestion about how your complaint could be resolved?

In certain circumstances, the IPC will make an order to resolve a complaint. However, it is important to note that most complaints before the IPC are resolved informally and do not result in an order. The IPC can order a health information custodian to improve its privacy practices, or stop an unauthorized use or disclosure of your personal health information, for example,

The IPC cannot order disciplinary measures against employees of the health information custodian you are complaining about (such as requiring the health information custodian to fire an employee) or order it to pay you financial compensation (money).

Attachments

Please attach any documents about your complaint or evidence of your role as a substitute decision-maker.
The following documents have been attached (if applicable):

Attach: (10MB maximum)

Signature: (required)

Use your cursor (or finger if on a smartphone) to enter your signature.

Signature Date: (required)

(MM/DD/YYYY)

Submit the form:

Option 1:   Send this form now

What happens next? Someone from our intake team will contact you to discuss your complaint.

Find out more about your health privacy rights and the complaint process.
You can also contact our office by email at [email protected], by phone at 416-326-3333, toll-free at 1-800-387-0073 if you have questions.
A PDF of this form is available for download.