BHS Release of Patient Information Request Form
Request date: <<Miscellaneous:Date (long)>>	V1
(20140423)	

REQUESTED BY
Name: <<Doctor:Name>>
Practice: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Provider #: <<Doctor:Provider Number>>
	PATIENT DETAILS
Name: <<Patient Demographics:Full Name>>
Gender: <<Patient Demographics:Sex>>
DOB: <<Patient Demographics:DOB (long)>>
Address: <<Patient Demographics:Full Address>>
Home ph: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Medicare #: <<Patient Demographics:Medicare Number>>
	
REQUEST DETAILS
Urgency: <<Urgency>>
		
INFORMATION REQUIRED (specify dates if known)
Discharge summaries: <<Discharge summaries>>
Outpatient correspondence: <<Outpatient correspondence>>
Operation reports: <<Operation reports>>
Investigations: <<Investigations>>
Other: 
		
PATIENT CONSENT (please tick & sign as appropriate)

 [  ]   I, the above named patient consent to the release of health information (including test results etc) about past and present illness to the Doctor or health care provider making this request. I understand this is necessary for my ongoing treatment.

Patient signature: ___________________________________________________  Date: _______________

 [  ]  It is impractical to provide patient consent at this time. I verify that I am treating this patient and the information is require for their ongoing treatment.

GP signature: ______________________________________________________  Date: _______________
	
OFFICE USE ONLY

Staff receiving request: _______________________________ Date: ___/___/____  Time: ___________

Staff member checked medical record for MR/052.0 or 052.1 (Use & Disclosure form) [   ]

Information sent by: [  ] Fax    [  ] Mail         # pages sent: ______________

Staff name: ________________________________________  Date: ___/___/____  Time: ___________
	
BHS endeavours to comply with the Health Records Act 2001 and other relevant legislation when handling health information. The health information enclosed is being provided to you on the understanding that it is to be used for its primary purpose or for a directly related secondary purpose. Disclosure of this health information to your service imposes on you an obligation to treat this information confidentially and in accordance with legislative requirements of the Health Records Act 2001 and Health Services Act 1988.

Patient Name:<<Patient Demographics:Surname>>, <<Patient Demographics:First Name>> DOB: <<Patient Demographics:DOB>>
Recipient: <<Addressee:Name>> Date of Report: <<Miscellaneous:Date>>