How to file a PHIPA statement of disagreement — and autofill 014-1469-41 with my-id.ca
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 my-id.ca.
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 my-id.ca makes it faster
- Save it once. Store your your name, address, and custodian contact details in your my-id.ca profile.
- Keep documents ready. Upload supporting documents to my-id.ca Files so you are not searching at form time.
- Autofill the form. Use the my-id.ca Chrome extension on a web form, or fill a PDF from your saved profile inside my-id.ca.
- Review and submit yourself through the official channel.
Why do it in my-id.ca
Related Ontario forms repeat the same personal details. Captured once in my-id.ca — stored in Canada, with AI on its own servers — every form starts mostly complete.
Frequently asked questions
- When should I use this form?
- When you disagree with information in your health record and want a statement attached under PHIPA — confirm rights on ontario.ca.
- How does my-id.ca help?
- It autofills your name, address, and custodian contacts across PHIPA access and correction forms.
- Can the custodian refuse my statement?
- Confirm custodian obligations and limits on ontario.ca; legal advice may be needed for disputes.
Fill it once. Reuse it everywhere.
Save your information in my-id.ca once, then autofill this form and the next one — web forms with the Chrome extension, PDFs right in the app. Your data is stored in Canada and AI runs on my-id.ca's own servers, never sent to third-party AI providers.