Access to Client Records Form

Country & Outback Health
Access to Client Records Form

Please complete all information required in the form fields below

Client Details

Title

Surname

Given Name

Previous Name(s) known by

Date of Birth

Residential Address
Address Line 1
City
State / Province / Region
Postal Code
This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

Phone Number

Email Address

Applicant Details

Title

Surname

Given Name(s)

Practice or company Name (if applicable)

Email Address

Phone Number

Address
Address Line 1
City
State / Province / Region
Postal Code

Details of Request

Do you want access to all or part of the client record?
All
Part

If partial access is required, describe clearly the documents you require:

What form of access do you require?

Yes No

a) I wish to inspect the documents
Yesa) I wish to inspect the documents Yes
Noa) I wish to inspect the documents No
b) I require a copy of the documents
Yesb) I require a copy of the documents Yes
Nob) I require a copy of the documents No
c) I require access in another form
Yesc) I require access in another form Yes
Noc) I require access in another form No

	Yes	No
a) I wish to inspect the documents	Yesa) I wish to inspect the documents Yes	Noa) I wish to inspect the documents No
b) I require a copy of the documents	Yesb) I require a copy of the documents Yes	Nob) I require a copy of the documents No
c) I require access in another form	Yesc) I require access in another form Yes	Noc) I require access in another form No

If yes to (c) please describe the form of access:

Client Consent to Release Information

Information will not be released to 3rd party unless consent has been authorised below by client.

I consent to my files being sent via secure, encrypted email (ShareFile) *
Yes
No

Who should the documents be sent to:
3rd Party Applicant
Client

What is the reason for your request?

Signature of 3rd Party requesting information:

Clear Signature

GP Provider Name

Practice Contact Number

Client Signature *

Clear Signature

I, (client / guardian) hereby consent to the release of information as requested.

Photo ID *

Click or drag a file to this area to upload.

Please upload a copy of your current photo identification

Date of Request

Website

Country & Outback Health Access to Client Records Form