PATIENT RELEASE OF INFORMATION

PATIENT RELEASE OF INFORMATION CONSENT FORM

Please complete this form and press "Submit"
Patient Name:*

First NameLast Name
Date of birth:*

DayMonthYear
Date
Email:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where would you like your medical information sent?*
Doctor's Name:*

First NameLast Name
Clinic/ Hospital's Name:*
Enter Clinic/Hospital's Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please specify which records you would like released: (Test results, consultation, reports etc)*
(Test results, consultation, reports etc)
Please provide method of delivery:*
(This request will be processed within *7 working days after this form has been submitted)
Email
example@example.com
Fax

Area CodePhone Number
Patient Consent Acknowledgement

Please read the statement below carefully before signing. By signing, you confirm your understanding and agreement.

I, the above-named patient, consent to Scope Healthcare releasing my health information to the doctor or healthcare provider I have nominated. If reports are given directly to me, I understand it is my responsibility to seek medical advice regarding their content. I understand that email is not secure, and Scope Healthcare will take reasonable steps to protect my privacy. I consent to being contacted regarding possible payment for historical results. I understand I may withdraw this consent at any time in writing.
Date*

DayMonthYear
Date
Patient Signature*

Clear
Scope Healthcare endeavours to process your request in accordance with the Health Records Act 2001 and Privacy Act 1988 (Cth).
Should be Empty:

PATIENT RELEASE OF INFORMATION CONSENT FORM