Information Access Request Form

Access to your health information along with the privacy of your health information is covered by the Australian Privacy Act 1988 (Cth). You can request a copy of information that the PHN holds about you by filling out the details below.

Your identity will need to be verified prior to releasing information, we may contact you by phone or email that we have on file to confirm. If a third-party is making the request we will require you to complete the 'Authority to Act Form ' to give us permission to release your information to them.

Once we receive this form we will respond to let you know if we have the information you are requesting and give you an approximate date of completion.

In rare cases the information we hold may be unable to be released for legal or safety reasons, if this is the case we will let you know in writing and give you more information on next steps.

About the person making this information request

Are you making this request for you or on behalf of someone else?

For myselfI am a legal guardian/ carer supporting the individual's requestI am a third party acting on behalf of the individual (solicitor, advocation representative)

About the person who the information request relates to

First Name *

Last Name *

DOB *

Phone Number *

Email Address

Address Line 1 *Unit/ Street number and street name

Address Line 2

Suburb *

Postcode *

State or Territory *

Please outline in detail the information that is required *Please be as specific as possible in your request, Please include specifics below such as relevant dates and clinician/ service details to ensure you get the information that you are seeking.

Clinician Name

Service Name

Approximate start date

Approximate end date