The information entered into this form is being collected by the Health Advocate pursuant to sections 20 and 22 of the Health Information Act, by the Mental Health Patient Advocate pursuant to 20 of the Health Information Act and by the Seniors Advocate pursuant to sections 33(c) of the Freedom of Information and Protection of Privacy Act for the purpose of referring the complainant to the appropriate health resource. If you have any questions regarding the collection, use and disclosure of this information, please contact the Manager, Investigations and Analysis at 12th Floor, Centre West Building, 10035-108 Street, Edmonton, Alberta, TSJ 3El or toll- free by phone within Alberta 310-0000 then 780-422-1812.
Select the option that best describes you: *
a clienta family member or a friend of a clienta health care service provider of a clienta legal guardian of a clienta member of an organizationa member of the general public
First Name: *
Day Time Phone Number: *
Email Address: *
City / Town:
Purpose of Contact (check all that apply):
File a complaint or concernGet help to navigate the systemGet informationRequest a presentationOther
Provide a brief description of the nature of the concern: *
There is a 200 word limit. Please identify the general nature of the complaint ONLY. Please DO NOT include health care numbers or detailed health information.
Please limit the description to 200 words.
The Office of the Health Advocates is comprised of the Health Advocate, the Mental Health Patient Advocate and the Seniors Advocate. I authorize the Health Advocate and the Mental Health Patient Advocate to disclose the information provided above to each other and to the Seniors Advocate for the purpose of referring me to an appropriate health resource. I understand and acknowledge why I have been asked to disclose the information I have provided above, and am aware of the risks or benefits of consenting to the disclosure of my information. I give my consent effective the date this form is submitted. This consent is given pursuant to s. 34 of the Health Information Act and section 40 of the Freedom of Information and Protection of Privacy Act. This consent is valid for 1 year. I am aware that my consent may be revoked at any time by contacting the Office of the Health Advocates at Manager, Investigations and Analysis at 12th Floor, Centre West Building, 10035-108 Street, Edmonton, Alberta, TSJ 3El or toll- free by phone within Alberta 310-0000 then 780-422-1812.
I agree to these terms *