What is a substitute decision maker for medical records requests?

The term substitute decision maker (SDM) generally refers to a person who is authorized to consent on behalf of an individual to the collection, use or disclosure of personal health information about a patient.

Under what circumstances would a substitute decision maker be required when requesting medical records?

- the patient is considered to be incapable of providing consent;
- the patient is a minor;
- the patient is deceased.

There are three types of substitute decision makers for the purpose of requesting medical records. They include: a parent or guardian, power of attorney, or an executor of the estate. In all cases it is up to the substitute decision maker to prove they have a legal right to their standing through different types of documentation. This documentation is submitted to the healthcare provider with the request for medical records.

What documents are acceptable to prove substitute decision maker status?

Acceptable:

  • Long form birth certificate
  • A court document designating a guardian
  • Power of attorney document (POA) for Personal Care (not property)
  • Original will
  • Certification of appointment as an estate trustee

Unacceptable:

  • Driver's license
  • Passport
  • Health card
  • Short form birth certificate

Grey Area (acceptable in some cases but not all):

  • Short form birth certificate AND parent's driver's license

If you do not have acceptable documentation on file, we recommend that you try to find the best equivalent to these documents. It is possible that these documents do not exist or or inaccessible for the purpose of making the request. Situations that involve substitute decision makers can be extremely difficult. It is always worthwhile to explain the situation you are facing to the healthcare provider and provide as much proof as possible of you relation to the patient. It is ultimately up to the discretion of the healthcare provider to release the patient's records.