|Classification / Identification:|
| ||Form Number:||014-5095-87E||Edition date: ||2018/07 |
| ||Title:||Consent to the Ministry of Health and Long-Term Care's Disclosure and Collection of Personal Health|
| ||Ministry:||Health|| || |
| ||Branch/ABC:||Drug Programs Delivery Branch|| || |
| ||Program:||Ontario Drug Benefit|| || |
| ||Purpose of Form:||MOHLTC form that allows an Ontario Drug Benefits (ODB) Recipient to submit their express consent to disclose their personal health information to a third party and consent for the Ministry to collect that information from a third party.|| || |
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