Central Health Breach Registration Form

 


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* Required information.
Have you or a family member been notified that your personal medical information was improperly accessed? *
Yes
No
I am submitting on behalf of somebody else.

Please enter the following information about the person whose privacy was breached:

Full Name *
Phone Number *
Email Address *
What is the best way for Bob Buckingham Law to contact you? *
Address
Address (line 2)
City *
Province *
Postal Code
Date of Birth *
Date of Death (if applicable)
Marital Status *
Spouse's Name (if applicable)
Spouse's Birth Date
Please indicate how this privacy breach has impacted/affected you? *
Questions/Comments *

Alternate Contact Information (if applicable)

Are you submitting this form on behalf of somebody else? *
Yes
No

If yes, please complete the following fields with your information.

Full Name
Relationship to Victim
Phone Number
Email Address
What is the best way for Bob Buckingham Law to contact you?
Phone
Email
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