|Classification / Identification:|
| ||Form Number:||014-4891-84E||Edition date: ||2022/01 |
| ||Title:||Request for Disclosure of Personal Claims History Information to a Third Party|
| ||Ministry:||Health|| || |
| ||Branch/ABC:||Claim Services Branch|| || |
| ||Program:||Claims Services|| || |
| ||Purpose of Form:||Form authorizes the ministry to disclose an individual's personal claims history information directly to a third party.|| || |
You must download Adobe Acrobat Reader (version 10.0 or above) to view/print PDF forms.
Click here for further instructions.
If PDF forms do not open in the latest versions of Firefox and Chrome, click here for the solution.
When encountering a problem opening PDF using a browser such as Chrome, please follow these steps to open and complete the form.
Highlight the form on the Repository, right-click to select “Save link as” to save the PDF form onto the desktop. Do not double-click the form and open it in a browser.
Open the form that you saved on the desktop with Adobe Reader. Do not double-click to open the PDF form as Adobe Reader might not be the default program to open PDFs on your computer.
Now complete the form, save the data, and close it. Then open again to see if the input data is there.