BHS Release of Patient Information Request Form
Request date: <FormattedDate>	V1
(20140423)	

Please fax to BHS Health Information Department on 5320 4829 

REQUESTED BY
Name: <DrName>
Practice: <Practice>
Address: <DrAddress>
Phone: <DrPhone>
Fax: <DrFax>
Provider #: <DrProviderNo>
	PATIENT DETAILS
Name: <PtFullName>
Gender: <PtSex>
DOB: <PtDoB>
Address: <PtAddress>
Home ph: <PtPhoneH>
Mobile: <PtPhoneMob>
Medicare #: <PtMCNo>
	
REQUEST DETAILS
Urgency: <Urgency>
		
INFORMATION REQUIRED (specify dates if known)
Discharge summaries: <Discharge summaries requested>
Outpatient correspondence: <Outpatient correspondence requested>
Operation reports: <Operation reports requested>
Investigations: <Investigations requested>
Other: 
		
PATIENT CONSENT (please tick & sign as appropriate)

c 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: ______________

c It is impractical to provide patient consent at this time. I verify that I am treating this patient and the information is required 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: c Fax    c 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.