Patient Consent to Release or Transfer of their Health Information

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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:..........................................................................

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________
________

________

________
________


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:..........................................................................