Access to Client Records Form

Title

Surname

Given Name

Previous Name(s) known by

Date of Birth

Residential Address

Street addressStreet address line 2

City

State

Postcode

Country

Phone Number

Email Address

Applicant Details

Title

Surname

Given Name(s)

Practice or company Name (if applicable)

Email Address

Phone Number

Address

Street addressStreet address line 2

City

State

Postcode

Country

Details of Request

Do you want access to all or part of the client record?

AllPart

If partial access is required, describe clearly the documents you require:

What form of access do you require?

YesNo

Records sent via a secure encrypted “ShareFile” email (free)

YesNo

Paper Copy (charges may apply for third party applicants)

YesNo

USB (charges apply for cost of USB and registered Australia Post mailing)

YesNo

Client Consent to Release Information

Information will not be released to 3rd party unless consent has been authorised below by client.

I consent to my files being sent via secure, encrypted email (ShareFile) *

YesNo

Who should the documents be sent to

3rd Party ApplicantClient

What is the reason for your request?

Signature of 3rd Party requesting information

Draw signature|Type signatureClear

GP Provider Name

Practice Contact Number

Client Signature *

Draw signature|Type signatureClear

I, (client / guardian) hereby consent to the release of information as requested.

Photo ID *

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Please upload a clear photo of yourself holding your current photo ID next to your face, making sure that both your face and the ID details are fully visible

Date of Request

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