Javascript must be enabled to complete this form. Please see https://www.enablejavascript.io for more information.
Please note authority to represent another individual will be subject to validation
Note: Please be ready with letter of authorization to be uploaded as attachment
This request cannot be fulfilled, the individual will have to submit for themselves.
Note:
The Manitoba Department of Health, Seniors and Long-Term Care (“MHSLTC”) is authorized to collect your personal information and personal health information on this form pursuant to clause 36(1)(b) of The Freedom of Information and Protection of Privacy Act, CCSM c F175 (FIPPA) and subsection 13(1) of The Personal Health Information Act, CCSM c P33.5 (PHIA). This collection is for the following purposes:
Any other use of your personal information or personal health information by MHSLTC must be authorized by FIPPA and/or PHIA.
MHSLTC may indirectly collect and disclose your personal information and personal health information, as necessary and where applicable, from and to the following entities:
The indirect collection and disclosure of your personal information and personal health information may be required to conduct any investigation needed to process your update request and to update your immunization record.
For MHSLTC to process your update request, you will be required to consent to MHSLTC indirectly collecting and disclosing your personal information and personal health information, as applicable, from and to the entities as described above.
MHSLTC will have the authority to indirectly collect and disclose your personal information and personal health information for the purposes indicated above under:
Sections 37(1)(a) and 44(1)(b) of FIPPA; and
Sections 14(2)(a) 22(1)(b) of PHIA.
____________________________________________________________________________________
Your consent is voluntary and you may withdraw your consent at any time by contacting:
Immunization Records Information at: stacey.bulat@gov.mb.ca
Your consent continues until you notify MHSLTC that you withdraw your consent. Your consent cannot be withdrawn retroactively.
If you do not provide consent or withdraw your consent prior to completion of your update request, MHSLTC will not be able to process your update request.
Your personal information is protected under FIPPA and your personal health information is protected under PHIA. MHSC, Shared Health and the Regional Health Authorities will only collect, use and disclose as much personal information and personal health information as is necessary and cannot disclose your personal information and personal health information for other purposes, unless it is authorized to do so under FIPPA or PHIA. For any questions regarding the collection, use or disclosure of your personal information and personal health information, please contact:
Stacey Bulat Manager, Public Health Information Systems Ph: 204-915-6052 stacey.bulat@gov.mb.ca
MHSLTC indirectly collecting and disclosing my personal information and personal health information as between MHSTLC and the following persons/entities, as necessary and where applicable, to complete the investigation required to process my update request and to update my immunization record:
NOTE: Subsection 90(1) of The Public Health Act provides that a person is guilty of an offence if they knowingly make a false or misleading statement to the minister, the chief public health officer, a director, a medical officer, an inspector, a health officer, a public health nurse or any other person acting under the authority of this Act; or knowingly make a false or misleading statement in an application, report, record or return given or required under this Act, or knowingly provide false or misleading information under the Act. A person, other than a corporation, who is guilty of an offence under the Act, is liable on summary conviction, to a fine of not more than $50,000 or imprisonment for a term of not more than six months, or both.
