Government of Ontario

Birth Family Member’s Guide to Completing an Application
for a Severe Medical Search

Important: Please read this guide thoroughly before starting the application process. Applications that are not complete or correct will be returned and the processing of the application will be delayed.

General Information

The purpose of a Severe Medical Search requested by a birth family member is to locate and contact an adopted person, or the descendents 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 as the result of a Severe Medical Search may benefit the adopted person, the descendent of the adopted person or the birth family member.

The Custodian of Adoption Information may conduct a Severe Medical Search only in regard to an adoption that was registered in Ontario.

Who should use this form?

This form can be used by eligible members of an adopted person’s birth family, by a person entitled to apply on behalf of a birth family member or in regard to a deceased birth parent. Birth family member means, with respect to an adopted person, the adopted person’s birth parents and any other person related to the birth parent including the birth grandparents and any birth siblings.

Do not use this form if you are a descendant of an adopted person (such as a child or grandchild). Descendents of an adopted person must use the Adopted Person’s and Descendent of Adopted Person’s Application to Request a Severe Medical Search.

The following people can use this form to apply to request consideration for a Severe Medical Search:

• a birth parent of an adopted person;
• a birth family member other than a birth parent, who has reached the age of 18;
• a parent or legal guardian of a birth family member (other than a birth parent) who is under 18 years of age;
• a person who is legally authorized to act on behalf of a birth family member.
• If a birth parent suffered from a severe mental and/or physical illness and has died, the following persons can apply in regard to the deceased birth parent:
  1. the spouse of the deceased birth parent;
  2. the executor of the deceased birth parent’s estate;
  3. a member of the College of Physicians and Surgeons of Ontario;
  4. a member of the College of Psychologists of Ontario;
  5. a member of the College of Nurses of Ontario who holds a certificate of registration in the extended class;
  6. a person who is legally authorized to practice medicine or psychology in a jurisdiction outside of Ontario.

Eligibility for a Severe Medical Search

The information you provide on the application form will be used to determine if you are eligible for a Severe Medical Search. The eligibility requirements of a Severe Medical Search are defined under Section 16 of O. Reg. 464/07 under the Child and Family Services Act. Severe Medical Search requests that do not meet the eligibility criteria will not be granted.

A Severe Medical Search for an adopted person or the descendant of an adopted person will be conducted if it is determined that the adopted person’s birth family member suffers from a severe physical and/or mental illness and would derive a direct medical benefit in the event that the adopted person or the descendant of an adopted person is located and contacted.

OR

There is reason to believe that the adopted person or the descendant of an adopted person will derive a direct medical benefit as a result of receiving the health information.

Direct medical benefit means a significant increase in the likelihood of diagnosing or treating a severe mental or physical illness. Severe physical or mental illnesses include those illnesses which are life-threatening or will lead to permanent or irreversible damage, impacting daily life. Verification of the nature, severity and urgency of the situation must be provided by an appropriate, regulated health care professional in Part D of the application form.

Completing the Application Form

The application form has five parts. Please fill out all of the information requested to the best of your ability by printing clearly in blue or black ink. Some sections of the application form will not apply to you and should be left blank.

Part D of the application form must be filled out by a physician or another appropriate regulated health care professional.

Part A: Applicant Information

Applicant Name

Please print your current, legal surname (your last name), your first name and any middle names you may have in the section provided.

Applicant Gender

Check the box on the form to indicate whether you are male or female.

Date of Birth

Enter your date of birth in the space provided. Birth family members (other than birth parents) must be 18 years of in order to apply for a Severe Medical Search. The parent of a birth family member may apply on behalf of a birth family member who is under 18 years of age. If you are a birth parent and are under 18 years of age, you are eligible to apply for a Severe Medical Search.

Mailing Address

Enter your mailing address in the space provided. A mailing address is necessary so we can mail you the results of your Severe Medical Search application. This address will be used for all correspondence relating to your application.

Daytime Telephone Number

Enter a daytime telephone number where you can be contacted during regular business hours. Check the box to indicate whether a message can be left for you at this number.

If it is not possible to leave a message at the daytime number you have listed, or if there is another telephone number where you may be reached (such as a cell phone number), enter that telephone number on the form. If you do not have an alternate telephone number, leave that space blank.

Additional Information about the Applicant

You must check the appropriate box on the form to indicate if you are:

• A birth parent.
  
  
• A birth family member other than a birth parent, who has reached 18 years of age. If you choose this option you must also indicate your relationship to the adopted person by checking the appropriate box. If you choose “other”, please specify the family relationship in the space provided.
  
  
• A parent or legal guardian of a birth family member (other than a birth parent) who is under 18 years of age. If you choose this option, you must specify the birth family member’s family relationship to the adopted person in the space provided.
  
  
• Applying on behalf of a birth family member as someone with the legal authority to act on their behalf. If you choose this option, you must specify the birth family member’s relationship to the adopted person in the space provided.
  
  
• Applying in regard to a deceased birth parent. If you choose this option, you must check the appropriate box to indicate your relationship to the deceased.

Purpose of the Severe Medical Search

A Severe Medical Search may be carried out in order to obtain or share medical information. You must indicate the purpose of your search by checking the appropriate box. You may check only one box.

Part B: Information about the Adopted Person PRIOR to Adoption

Instructions for Birth Parents

If you are a birth parent please fill in the information requested in this section to the best of your ability. Please try to include at a minimum:

• Name of Adopted Person - Enter the adopted person’s legal surname (last name), first name, and middle name(s) at the time of their birth.
• Sex – Check the box to indicate whether the adopted person is male or female
• Date of Birth – Enter the date of birth of the adopted person. You may enter an approximate date if the exact date of birth is not known.
• Name of Birth Mother – Enter the birth mother’s name at the time the birth took place.

Additional information requested in this section of the application may help speed the application process, but is not required.

Instructions for Birth Family Members

If you are a birth family member other than a birth parent and know the birth name of the adopted person, or are aware of some of the particulars of the adopted person’s birth parents, or other birth details prior to the adoption, please provide those details in this section.
Please try to include at a minimum:

• Name of Birth Mother – Enter the birth mother’s name at the time the birth took place.
• Sex – Check the box to indicate whether the adopted person is male or female
• Date of Birth – Enter the date of birth of the adopted person. You may enter an approximate date if the exact date of birth is not known.

Additional information requested in this section of the application may help speed the application process, but is not required.

Part C: Information About the Adopted Person AFTER Adoption

If as a birth parent or a birth family member you are aware of some of the particulars of the adopted person after adoption, please provide those details in this section. Otherwise, you may leave this section blank.

Part D: Health Care Professional Questionnaire

The information provided in the Health Care Professional Questionnaire 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.

Important

The Health Care Professional Questionnaire must be submitted with your Severe Medical Search Application. Applications that do not include a completed Health Care Professional Questionnaire will be returned to the applicant

Patient Name

This section must be completed by the applicant.

If you are a birth parent or a birth family member, please print your current, legal name in the section provided.

If you are applying on behalf of a birth family member or in regard to a deceased birth parent, you must print his or her current or last known legal name in the section provided.

Patient Consent to Disclose Health Information

In order for your health care professional to fill out the Health Care Professional Questionnaire the Patient Consent section must be completed. Please fill in the requested information including the name of the health care professional that will be completing the questionnaire. You must sign and date the consent statement.

Health Care Professional’s Information

The remainder of the Health Care Professional Questionnaire must be completed and signed by an appropriate regulated health care professional.

The health care professional must provide his or her full legal name in the space provided and indicate his or her professional designation by checking the appropriate box. If the health care professional is a member of a professional association or college that is not listed on the application form, he or she may check the box titled “other” and must provide further details in the space provided.

The health care professional must also enter a business mailing address and a daytime telephone number where they can be reached during regular business hours

Questions Regarding the Patient’s Health Condition

The information provided in response to these questions will be used to determine if an applicant meets the eligibility requirements for a Severe Medical Search. The health care professional must answer each question by checking the appropriate box. If the answer to a question is “yes” further details must be included in the space provided. If additional space is required additional pages may be added.

The health care professional must sign and date the questionnaire and return it to the applicant. As confirmation that he or she is a regulated health professional, a business card or letterhead must be affixed to the questionnaire as indicated. Alternatively, he or she may stamp or seal the questionnaire in the box indicated on the form.

Please note that the Custodian of Adoption Information may contact the health care professional who completes the Health Care Professional Questionnaire.

Part E: Signed Statement by the Applicant

The applicant must sign and date the application as indicated in Part E in order for it to be processed.

Mailing Instructions

Mail your completed Severe Medical Search Application including the Health Care Professional Questionnaire to:

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

Applications that do not include a signed, completed Health Care Professional Questionnaire will be returned to the applicant.

If you have any questions please contact:

ServiceOntario
Toll-free: 1 800 461-2156 or
Toronto: 416 325-8305

Version française disponible