​Patient Removal Request Form
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Process to request removal of physician from patient admission/registration and report misdirected records belonging to Interior Health Authority. If you received misdirected records from another health authority/organization, do not complete this form; please send your correction request to the owner of those records.
 
An accurate patient record is critical to ensuring timely and appropriate health care. When physicians move/retire, patients change health care providers, or data entry errors occur, this may result in records being misdirected. This encrypted online form allows physicians and healthcare professionals to securely report and quickly correct this matter.
 
Any related misdirected records MUST be attached with your request specific to each patient. These records contain details we need to investigate the matter and without them there is no guarantee the issue can be completely fixed.
 
Please keep these records in a safe place for 3 business days, in case we need you to resend them. After such time, destroy the records by secure shredding.
 
NOTE: If a healthcare provider’s contact information needs to be updated, do not complete this form; please call IH IMIT Service Desk 1-855-242-1300 for assistance.

 

This form is intended to be used solely for official purposes by authorized personnel.  Unauthorized access or use may subject violators to criminal, civil and administrative actions.

 

MoH     PCQO