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)

Name of person making the request

Phone number of the person making the request

Email of the person making the request

Authority to Act Form

About the Authority to Act Form...

Authority to Act forms are documents that allow an individual to authorise a trusted person to act on their behalf.

The authority to act only applies to this specific request, authorisation is not ongoing and does not extend to different matters.

We cannot action the information access request until we have received a signed Authority to Act form from the person who the information request relates to.

We will also take steps to verify the identity of the person prior to actioning the request.

Download the form here Authority to Act Form

Once signed, please copy and save the document and upload the file below. Click Browse button below to select your file and upload.

You may upload the "Authority to Act Form" here *

Browse

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

Signature of the person who the requests relates to *

Draw signature|Type signatureClear