Fillable Printable Authorization Letter (Template)

Authorization Letter (Template)

Date:

To: Manitoba Health c/o Secretary of the MDSTC

Reference: (drug name, strength and dosage form)

This letter authorizes Manitoba Health to gain access to all information with

respect to the product in the possession of Health Canada, the government of

any province or territory in Canada, or the Patented Medicine Prices Review

Board; and authorizes disclosure of any information with respect to the product in

the possession of Manitoba Health to Health Canada, to the government of a

province or territory in Canada, to the Canadian Coordinating Office for Health

Technology Assessment (CCOHTA), to a Regional Health Authority in Manitoba

established under The Regional Health Authority Act or to the Patented Medicine

Prices Review Board.

(signature)

(Name and Title of Senior Company Official)