Medical Records Request

    AUTHORISATION TO RELEASE MEDICAL RECORDS

    PATIENT DETAILS










    RECIPIENT DETAILS







    I AUTHORISE THE RELEASE OF MY MEDICAL RECORDS TO THE ABOVE NAMED ADRESSEE/PRACTICE
    I AKNOWLEDGE THAT FILE TRANSFERS CAN TAKE UP TO 4 WEEKS TO BE COMPLETED

    Please note, if we are releasing your medical file to you personally, there is an administrative fee of $10.00 PLUS .20c per page if medical file is over 5 pages (first 5 pages at our cost)
    This fee is in accordance with the regulations under the Health Records Act 2001 and covers:
    • Assessment and Collation of your health information
    • Retrieval of any offsite records
    • Photocopying / scanning expenses
    • Registered Mail (required for security and confidentiality of your personal information)

    FEE IS PAYABLE PRIOR TO RELEASE OF ANY MEDICAL INFORMATION.

    Payment can be made by credit card or by direct deposit to:
    Account: Health On Collins Pty Ltd
    BSB: 083 170
    Account Number: 860 887 238
    Bank deposit reference: Surname

    If you request your file to be emailed, it must be sent encrypted for the security and privacy of your personal medical information. A password to enable you to open the encrypted email will be supplied. The same administrative fees will apply.