Service User - Records Request

Service User - Records Request

Progress to Health
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
YOUR SERVICE USER RECORDS
The Health Information Privacy Code 2020 requires Progress to Health to retain service user records for 10 years after our last contact with you.

At the end of this period, we are required to make a reasonable attempt to reach you either via your last known address or other contact details you may have given us. The purpose for this is to give you the opportunity to have a say in whether the records are returned to you or destroyed.

Please complete this form or contact us at admin@progresstohealth.org.nz. If we haven’t heard from you by the given date, we will assume that you do not want your records and they will be destroyed.
Choose one option:*
EMAIL

If you are choosing to have your records sent via email, we will send a test email to verify your identity.
E-mail
ex: myname@example.com
POSTAL ADDRESS

If you are choosing to receive your records by post, we will then call you to verify your identity. Please note that if your records are sent via post, we cannot guarantee the safety of your personal information.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DECLARATION
By signing below, I certify that the information provided in this request is true and accurate to the best of my knowledge. I understand that:
- This request is subject to applicable laws and regulations governing access to records.
- I may be required to provide additional identification or documentation to process this request.
- Processing times may vary depending on the nature and scope of the request.
Signature*

Clear
Please verify that you are human*
Should be Empty:

Service User - Records Request

YOUR SERVICE USER RECORDS

EMAIL

POSTAL ADDRESS

DECLARATION