Patient details

Patient surname

Patient first name

Street address

Suburb/town

Postcode

Phone

Date of birth

Email Address

UR No. (if known)

Applicant details (if different from above)

Company name (if applicable)

Applicant surname

Applicant first name

Street address

Suburb/town

Postcode

Phone number

Email Address

Relationship to patient

For request relating to children under the age of 16

Is the child subject to a Family Court Order?
YesNo

Please attach copy of Court Order

Documents requested

Describe clearly the documents you wish to access (include date range, subject matter, types of documents)
E.g. discharge summaries, clinical/progress notes, radiology and pathology results, correspondence and referral letters, medication records, observation charts, care plans.

Reason for request
This will assist us to identify and locate documents relevant to your request.

Are you willing to receive edited documents?
Yes: the document will be released with any exempt material deleted and clearly marked. No: the document will be refused in full.
YesNo

Forms of access
Copy of documents orInspect documents

Delivery of documents
Email (no delivery charge); orRegistered mail (delivery charges involved); orCollection in person (no charge) from the main hospital, with photo ID

Authority to access information

You must provide signed authority from the patient to release their information or provide evidence that you have the authority to access this information. If a patient is a child under the age of 16 and there are legal circumstances that may impact on the release of the child’s information, evidence that you have the right to access the patient’s information must be provided (i.e. a copy of the Family Court Order).

Signed authority from patient

Further evidence (if required)

Request for information relating to a Deceased Individual

Where the patient is deceased, the patient’s senior available next of kin must provide evidence that they are the next of kin (ie. Copy of the death certificate) and sign an authority to release the information if release is to a third party.

Death certificate

Signed authority by Senior NOK (if release is to a third party)

Fees And Charges

A $33.60 application fee (non-refundable) must accompany this form before the processing of this request can begin. For waiver of the application fee, please provide a copy of your valid Health Care Card or Pension Card or other evidence of hardship

Access charge

In addition to the application fee, the following access charges may apply. If applicable, you will be notified by mail of the relevant charges, which must be paid before you can access the documents. Do not pay these charges now. Search and retrieval , $15 per hour. Decision-making, $20 per hour (first 5 hours are free). Photocopying, 10 cents per A4 page. Transcript, $4.40 per A4 page.

Payment of the application fee
Cheque or Money Order made payable to Heathcote HealthCredit card – Attend in person or phone hospital main switch (03) 5431 0900Direct deposit via EFT - Attend in personIn person - Attend

Evidence for fee to be waived (if applicable)
Please specifyHealth care cardPension cardOther

Evidence for fee to be waived - evidence of hardship (if applicable)

Include photo identification that clearly shows your signature (e.g. driver licence or passport)