Attach a statement of disagreement to your health record without retyping identity details

Individuals who disagree with information in their personal health record repeat their full legal name, address, and health care provider contact when filing a PHIPA statement of disagreement. This guide is an example of storing them once in hivi.

Official form and source

Start from the official source and always use the current version — form numbers and links can change:

• Service page: OHIP and your personal health information — ontario.ca
• Form (Central Forms Repository): Statement of Disagreement with the Record of Personal Health Information — 014-1469-41

What this form is about

Form 014-1469-41 is the Statement of Disagreement with the Record of Personal Health Information, used under PHIPA when a person disputes information held by a health information custodian and requests that a statement of disagreement be linked to the record — confirm procedures on ontario.ca.

Before you start: what to gather

• Your full legal name and current address.
• Health information custodian name and contact.
• Record or entry you disagree with (date, description).
• Written statement of disagreement — prepare the narrative yourself.

Confirm the current process on ontario.ca.

How hivi makes it faster

1. Save it once. Store your your name, address, and custodian contact details in your hivi profile.
2. Keep documents ready. Upload supporting documents to hivi Files so you are not searching at form time.
3. Autofill the form. Use the hivi Chrome extension on a web form, or fill a PDF from your saved profile inside hivi.
4. Review and submit yourself through the official channel.

Why do it in hivi

Related Ontario forms repeat the same personal details. Captured once in hivi — stored in Canada, with AI on its own servers — every form starts mostly complete.