Request for transfer of Medical Records

Request for transfer of Medical Records

Dr Raymond Mullins, previously of Suite 1, John James Medical Centre, Deakin ACT 2600. NOTE: before requesting a copy of records, please check if you have already been supplied with a copy of your consultation letter, as these are your records. Almost all requests thus far are from individuals who were already sent copies of their letters following initial or subsequent consultations. From January 2025, fees may apply.
Name of patient

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (desirable as records can be sent by email)
example@example.com
Phone Number
Please enter a valid phone number.
Date of birth of patient

MonthDayYear
Date
Date of request

MonthDayYear
Date
Where to send the records

Patient (self)-this is the BEST option as you can take it to any new GPA medical practice (need contact/address details)
If to send to a medical practice that you are not already attending, please type in the practice name, address and other contact details (eg. fax, email)
OTHER TEXT
Should be Empty: