Personal Health Information Request Form

TOTARA HOUSE CLINIC

Ear Nose and Throat Specialist Centre
PERSONAL HEALTH INFORMATION REQUEST FORM

Your medical notes are private to you only. We protect your privacy by restricting access to these notes. We are unable to release notes to another person unless an authority is in place. The originals will be kept by Totara House Clinic.
I have the following authority to request this information:

I am the patientI am the parent/guardian of the child who is under 16 years of ageI have written consent from the patientI have lawful authority (e.g. power of attorney) over the person's affairsI have authorisation from the executor of the deceased person's estate
Patient Details

Person whose records are to be accessed
Full Name

First NameMiddle NameLast Name
Date of Birth

DayMonthYear
Date
NHI Number
Full Residential Address

Street Address

Suburb

CityState / Province

Postal Code
Contact Phone Number

Area CodePhone Number
Requestor's Details

If you are not the patient
Name of Person Requesting this Information:

First NameLast Name
Full Residential Address

Street Address

Suburb

CityState / Province

Postal Code
Contact Phone Number

Area CodePhone Number
Relationship to Patient:
Please attach evidence of representative status and/or lawful authority and photo proof of you own ID to this form.

Browse Files

Cancelof
Date Information Required:

DayMonthYear
Date
If the request is urgent please state reason why:
Every effort will be made to meet required timeframes. In accordance with the Privacy Act 2020 we will respond to your request no later than 20 working days after date of receipt.
Manner in which information is requested:

CollectEmailPost
Email Address
Please note that Totara House Clinic does not recognise email as always being a secure means of providing information and cannot take any responsibility for information that is accessed or received by others.
We will contact you when the information is ready to be collected.
Postal Address

Street Address

Suburb

CityState / Province

Postal Code
Requestor's Name

First NameLast Name
Signature
Date Signed

DayMonthYear
Date

TOTARA HOUSE CLINIC

PERSONAL HEALTH INFORMATION REQUEST FORM

Patient Details

Requestor's Details