Request To Access Medical Records Form

ADVERTISEMENT

TI-TREE FAMILY DOCTORS
REQUEST TO ACCESS MEDICAL RECORDS FORM
I, __________________________________ of ________________________________________
insert
patient name
address
(please tick one)
request access to; or
give consent for _______________________________________ to access
the documents listed on the following pages, in Table A.
I have been advised of the applicable administration fee for this service, charged in accordance Health
Records Regulations 2002 (Vic), which is not redeemable via Medicare.
I understand the Practice may request I attend a consultation with my doctor to discuss the information
contained in my medical record. In this instance, a consultation fee will apply which is not redeemable via
Medicare.
I understand I will not be permitted to remove, amend or delete any contents from my medical record. If
I wish to make any amendments or deletions, I must submit a request in writing to the Practice using the
Request to Amend Medical Record Form.
I understand I am permitted to obtain copies of some or all of the contents of my medical record. Copies
may not be available immediately at the time of inspection but will be made available to me as soon as
practicable after the inspection.
Under the Privacy Act 1988 (Cth) and the Health Records Act 2001 (Vic), you have a legal right to access
the personal information Ti Tree Family Doctors holds about you (such as your medical record), subject to
some exceptions.
PAGE 1/3

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3