Government of Ontario

Birth Family Member's Application to Request a Severe Medical Search

(THIS SPACE RESERVED FOR OFFICE USE ONLY)

BRI  _____________    CID   _____________



If you have any questions, please contact:
ServiceOntario
Toll-free: 1 800 461-2156 or
Toronto: 416 325-8305

Important:
Please read through the instructions thoroughly before completing this form. Please print clearly in blue or black ink.

PART A: Applicant Information

Applicant Name










Sex


Mailing Address


















Daytime Telephone Number

(

Can a message be left for you at this number?

Alternate Telephone Number

(

Additional Information About the Applicant

Please identify if you are (check only one box)

          
          

          
          
          
          

     

          
          
          
          

          

          

The purpose of the search is (check only one box)





PART B: Information About the Adopted Person PRIOR to Adoption






Sex

   



Place of Birth of Adopted Person






Birth Mother










Place of Birth






Birth Father










Place of Birth






PART C: Information About the Adopted Person AFTER Adoption






Sex


Has the person named above had a legal name change after adoption?

If "Yes" provide details below






Place of Birth of Adopted Person






PART D: Health Care Professional Questionnaire

Patient Name






Patient Consent to Disclose Health Information

I, , hereby authorize to disclose any health information required to the Custodian of Adoption Information, or his or her designate, to support my application for a Severe Medical Search under section 16 of O.Reg. 464/07 made under the Child and Family Services Act.


  

Important:
The following section must be completed by a physician or other regulated health care professional. Please print clearly in blue or black ink.

Health Care Professional's Information






Business Address
















Daytime Telephone Number

(

Health Care Professional's Designation (check appropriate box)






Important
The purpose of a Severe Medical Search is to locate and contact an adopted person, the descendant of an adopted person, or the birth family member of an adopted person in order to obtain or share medical information that will significantly increase the likelihood of diagnosing or treating a severe mental or physical illness.

The information obtained may benefit the adopted person, the descendant of the adopted person, or the adopted person's birth family member.

The information provided in the Health Care Professional Questionnaire is collected and will be used to determine the applicant's entitlement to a Severe Medical Search under section 16 of O.Reg. 464/07 made under the Child and Family Services Act. If you have any questions about the collection of information please contact: Director, ServiceOntario Call Centre, Contact Centre Service Branch, 5775 Yonge St, Toronto ON  M3M 3E6 or call 1 800 461-2156 / 416 325-8305.

Is the health information being sought essential to the patient's
diagnosis and/or treatments?

  

Is there a genetic reason to seek or pass on this information?

  

Are there any adverse health effects in denying this request for a
Severe Medical Search?

  

Is there any other information that you would like to provide in
support of this application?

  

Signed statement by health care professional

I, certify that the information I have given is true and correct to the best of my knowledge and belief.


  


Please stamp below or attach a business card or letterhead






PART E: Signed Statement by the Applicant

I hereby certify that the information I have provided on this application form is true and correct to the best of my knowledge and belief.


  

Mail your completed application, including the Health Care Professional Questionnaire to:

Custodian of Adoption Information
P.O. Box 654
77 Wellesley St. West
Toronto ON  M7A 1N3

The information provided on this form is collected and will be used to determine your entitlement to a Severe Medical Search under section 16 of O.Reg. 464/07 made under the Child and Family Services Act. If you have any questions about the collection of information please contact: Director, ServiceOntario Call Centre, Contact Centre Service Branch, 5775 Yonge St, Toronto ON  M3M 3E6 or call 1 800 461-2156 / 416 325-8305

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