Freedom of Information Application

Applicant's Details

Name/Agency*

Postal Address*

Street Address Suburb State Post Code

Email Address*

Enter Email Confirm Email

Mobile

Telephone*

Relationship of Applicant to Patient*

Other (Please Specify)*

Healthcare Number/Pension No.

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 64 MB.

A copy of both sides of healthcare/pension card must be provided

Upload photo identification/or proof of relationship*

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 64 MB.

Photo identification/or proof of relationship to patient is required

Hidden

Patient Details

Patient's Name*

Given Name Surname

Patient's Date of Birth*

Healthcare Number/Pension No.

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 64 MB.

A copy of both sides of healthcare/pension card must be provided

Form of Access

Form of Access*

Northern Health has a combined Medical Record. Please specify which service notes you require.

Information Required*

Upload letter*

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 64 MB.

Please provide a letter explaining the amendment

Please specify information required*

0 of 200 max characters

Collection of Information

How would you like to receive the documents?*

Address*

Street Address Suburb State Post Code

Who will be collecting the documents in person?*

Nominated Person*

I nominate the above person to collect the documents on my behalf. I understand the nominee will be required to produce photo ID on collection and a copy of that ID will be kept with the record of this application.

Identification will be required at point of collection.

Fees

Fees*

I acknowledge there will be additional costs for processing and postage as per section 22 and 23 of the FOI Act. I understand that under the FOI Act, some information may be exempt from release and relevant third parties may be contacted during the processing of the request and the applicants name will be used during this consultation process. If required, the relevant parties will be notified of exemptions and rights of appeal for this request.

Please note, a member of our team will be in contact with you for payment details.

Applicant Name*

Today's Date*

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Freedom of Information Application