________
________
________
________
________
RE: Consent to Release or Transfer of Health Information
To Whom It May Concern,
I am writing to give ________ consent to release or transfer (hereinafter "transfer") my health information, as detailed below. My details are as follows:
Name: ________
Date of birth: ________
Address:
________
1. Information to be transferred:
I consent to the transfer of the following information:
________
2. Purpose of the transfer:
I am consenting to this transfer of information, for the following purpose:
________
3. Recipient of the information:
I consent to the information being transferred to the following person/organisation:
Name of organisation: ________
Address: ________
Phone: ________
Email: ________
Relationship to patient: ________
4. Method of transfer:
I request that you use the following method to transfer my information to the above organisation:
________
5. Duration of consent:
This consent is valid until you receive a written notice of revocation from me.
6. Right to revoke consent:
I understand that I have the right to revoke this consent at any time by providing written notice to you. I am aware that the revocation will not affect any actions taken before the receipt of my written revocation.
7. 882228825222222 22 2588582 582528:
5 58222882522 2552 5 5582 8222 82225225 22 22 2588582 582528 52525 252 Australian 2588582 Principles 525 252 Health 8282558 Act, 525 2552 ________ 558 25222 82228 22 228552 2552 22 525825 82225252822 8888 82 5525825 82 5882555282 8825 25282 8588.
8. Patient signature:
By signing below, I confirm that the above information is true and correct and that I am providing this consent voluntarily.
Patient signature: ..........................................................................
Print patient name:..........................................................................
Date of signing:..........................................................................
Witness signature: ..........................................................................
Print witness name: ..........................................................................
Witness phone: ..........................................................................
Witness email: ..........................................................................
OFFICE USE ONLY:
Received by:..........................................................................
Date of receipt:..........................................................................
Method of transfer of information:..........................................................................
Date of transfer:..........................................................................
________
________
________
________
________
RE: Consent to Release or Transfer of Health Information
To Whom It May Concern,
I am writing to give ________ consent to release or transfer (hereinafter "transfer") my health information, as detailed below. My details are as follows:
Name: ________
Date of birth: ________
Address:
________
1. Information to be transferred:
I consent to the transfer of the following information:
________
2. Purpose of the transfer:
I am consenting to this transfer of information, for the following purpose:
________
3. Recipient of the information:
I consent to the information being transferred to the following person/organisation:
Name of organisation: ________
Address: ________
Phone: ________
Email: ________
Relationship to patient: ________
4. Method of transfer:
I request that you use the following method to transfer my information to the above organisation:
________
5. Duration of consent:
This consent is valid until you receive a written notice of revocation from me.
6. Right to revoke consent:
I understand that I have the right to revoke this consent at any time by providing written notice to you. I am aware that the revocation will not affect any actions taken before the receipt of my written revocation.
7. 882228825222222 22 2588582 582528:
5 58222882522 2552 5 5582 8222 82225225 22 22 2588582 582528 52525 252 Australian 2588582 Principles 525 252 Health 8282558 Act, 525 2552 ________ 558 25222 82228 22 228552 2552 22 525825 82225252822 8888 82 5525825 82 5882555282 8825 25282 8588.
8. Patient signature:
By signing below, I confirm that the above information is true and correct and that I am providing this consent voluntarily.
Patient signature: ..........................................................................
Print patient name:..........................................................................
Date of signing:..........................................................................
Witness signature: ..........................................................................
Print witness name: ..........................................................................
Witness phone: ..........................................................................
Witness email: ..........................................................................
OFFICE USE ONLY:
Received by:..........................................................................
Date of receipt:..........................................................................
Method of transfer of information:..........................................................................
Date of transfer:..........................................................................
Answer the question, then click on "Next".
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