Consent to Disclose
If you have any questions regarding the collection, use and disclosure of your personal information, please refer to our privacy statement or contact our Privacy Officer at (780) 431-4786 or po@asebp.ab.ca.
ASEBP 130 - Consent to Disclose Personal Information
Use this form if you are 16 years of age or older, or the legal guardian of a child under the age of 16 years, to indicate your consent for ASEBP to disclose your personal information to the people/organizations you specify. This consent is being obtained in accordance with sections 7, 8, 9, and 61 of Alberta’s Personal Information Protection Act. Complete each section in the form because incomplete forms will not be accepted.
Read the acknowledgement in Part 4 and sign and date the bottom of the page. Return this form to ASEBP at the address at the top of the form.
Note: Provincial privacy legislation states that beneficiaries of a benefit plan other than the applicant (e.g., spouse or child) are deemed to consent to the collection, use and disclosure of their personal information for the purpose of enrolment in or coverage under the benefit plan. Accordingly, express consent from dependents is no longer required as of May 1, 2010. Consent from dependents will be required for any use or disclosure that is not consistent with administration of the benefit plan.
ASEBP 130A - Consent to Disclose (Provided by 3rd party)
This form is to be used by a person who has designated legal authority to act on behalf of the individual whose personal information is to be disclosed when that individual is 16 years of age or older but incapable of understanding and/or making personal decisions and/or signing this document.
A copy of the appropriate legal designation documentation must be provided (custody or guardianship order, personal directive, power of attorney). This consent is being obtained in accordance with sections 7, 8, 9, and 61 of Alberta’s Personal Information Protection Act. Complete each section of the form because incomplete forms will not be accepted.
Read the acknowledgement in Part 4 and sign and date the bottom of the page. Return this form to ASEBP at the address at the top of the form. |
