Your health information (including Personal Health Number) on this form is collected under the authority of sections 20(a)(b), 21(1)(a), and 27(1) and (2) of the Health Information Act (“HIA”). The information will be used or disclosed by AHS as authorized by the HIA, for the purposes of providing or determining your eligibility for health services, planning, resource allocation, management of the health system; and activities related to AHS’ mandate to protect and promote public health. If you have any questions about the collection or use of your information or the completion of this form, please contact the Manager, Clinical Support Systems, 10101 Southport Rd SW Calgary AB. Phone number: (403) 943-0295.