Fillable Application for Prison Health Records (Department of the Environment and Energy)

Fill Online, Printable, Fillable, Blank Application for Prison Health Records (Department of the Environment and Energy) Form

Use Fill to complete blank online DEPARTMENT OF THE ENVIRONMENT AND ENERGY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application for Prison Health Records (Department of the Environment and Energy)

On average this form takes 6 minutes to complete

The Application for Prison Health Records (Department of the Environment and Energy) form is 1 page long and contains:

  • 1 signature
  • 8 check-boxes
  • 18 other fields

Country of origin: AUSTRALIA
File type: PDF

Use our library of forms to quickly fill and sign your Department of the Environment and Energy forms online.

BROWSE DEPARTMENT OF THE ENVIRONMENT AND ENERGY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Administration Access Application Page 1 of 2 Release of Information
Application for Prison Health Records
Privacy notice: The Hospital and Health Boards Act 2011 imposes strict confidentiality requirements. Information requested in this application
is to verify your identity to protect your personal health information from being disclosed to persons other than you or your authorised agent. If
your request contains sensitive material, third party or mental health information, it will need to be requested under the Right to
Information/Information Privacy Acts 2009. You will be informed of this change and the expected date that the application will be completed.
Section 1: Applicant details (please print or type)
Surname / family name: ………………………………………………………………………………………… IOMS: …………………………
Given names:
……………………………………………………………………………………………………… DOB: ……………………………
E-mail: ……………………………………………………………………………………… Day-time contact phone: …………………………
Postal address: ………………………………………………………………………………………………………………………………………………
Suburb/Town: ……………………………… State/Territory: …………………………… Postcode: …………………………………
Section 2 Request Type
Are you seeking access on someone’s behalf?
No, I am the patient (please continue to Section 3: Information)
Yes, I am an agent and informed consent from the patient is attached. The patient details are:
Patient’s Surname / family name: …………………………………………………………………………… DOB: …………………………
Given names: …………………………………………………………………………………………………… IOMS: …………………………
Section 3: Information
What information you are requesting:
(for example: facility where you were treated and date or date range, treatment or specific injury)
my complete medical records
relevant records between the dates: …………………… to ………………………
specific records including:
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
Section 4: Preferred access type
Email (indicated above)
Photocopy of documents
CD
Applicant’s Signature: ……………………………………………………………………… Date: …………………………………………
How to Apply
Patients currently incarcerated may provide this form and a copy of their ID to the medical centre within their correctional centre.
Alternatively, requests can be made via email or post (addresses listed on the second page).
Agents – authority and proof of identity
Please see over the page for proof of identity options
If you are an agent acting on the person’s behalf, please provide:
• Proof of your authorisation to act on the person’s behalf and access the person’s medical record
• Proof of your identity
• Certified copy of the persons/patient’s identity
Queensland Health or Corrective Services staff can sight proof of identity if the application is lodged in person.
RESET FORM
click to sign
signature
click to edit
Administration Access Application Page 2 of 2 Release of Information
Proof of identity
Category A: One (1) form of identification such as:
• Prisoner identity card certified by a corrective services
officer
• Current Australian photo driver’s licence, front and back
• Adult Proof of Age card (formerly the 18+ card)
• Current Australian passport (copy identifying page)
• Current overseas passport
• Current Defence Force or Police Service photo ID card
• Current Australian Firearms licence
If unable to provide identification from category A, two from category B is acceptable including one with a signature
Category B: Options include two (2) forms of identification (at least one containing a signature) such as:
• A copy of a certificate or extract from a register of births
• Current Medicare card
• Current financial institution debit or credit card with your
signature
• Current entitlement / pension card issued by th
e
C
ommonwealth or State Government
• Public Service employee ID card
• Educational institution student identity document (must
include photo and/or signature)
• School or other educational report, less than 12 months old
• Australian Marriage Certificate
If unable to provide two forms of identification from the category B, one from category B with a signature and one from Category C is acceptable
Category C: Options include forms of identification such as:
• Recent utility account (e.g. gas, electricity, home phone)
with current residential address
• Recent financial Institution statement with current
residential address
• Rent/Lease agreement with current residential address
• Rates notice in your name with current residential address
• Recent official correspondence from Government Servic
e
Providers (not from this agency) with current residential
address
• PAYG payment summary, less than 2 years old, with tax fil
e
number
Where to Send Application
Patient Location Release of Information Service Contact Information
Patient is discharged
Release of Information
Prison Health Services
Locked Bag 500
Archerfield, QLD 4108
prisonhs@health.qld.gov.au
(07) 3271 8640
Arthur Gorrie Correctional Centre
Borallon Training & Correctional Centre
Brisbane Correctional Centre
Brisbane Women’s Correctional Centre
Brisbane Youth Detention Centre
Helena Jones Centre
Southern Queensland Correctional Centre
Wolston Correctional Centre
Capricornia Correctional Centre
Release of Information Unit
Rockhampton Hospital
Canning Street
Rockhampton, QLD 4700
CQHHS.ROI.Privacy@health.qld.gov.au
(
07) 4920 6208
Lotus Glen Correctional Centre
Release of Information Unit
Cairns Hospital
PO Box 902
Cairns, QLD 4870
CHHHS-RTI-Pr
ivacy@health.qld.gov.au
(07) 4226 8680
Maryborough Correctional Centre
Legal Services Unit
Harvey Bay Hospital
PO Box 592
Pialba, QLD 4655
WBHHS-LegalServices@health.qld.gov.au
(07) 4325 6857
Numinbah Correctional Centre
Information Access Unit
Gold Coast Hospital
1 Hospital Boulevard
Southport, QLD 4215
GCHHSInformationAccessUnit@health.qld.gov.au
(07) 5687 3849
Palen Creek Correctional Centre
Information Access Unit
Logan Hospital
PO Box 6031
Yatala, QLD 4207
IAU.LBC@health.qld.gov.au
(07) 3299 8979
Townsville Correctional Centre
Townsville Women’s Correctional Centre
Cleveland Youth Detention Centre
Clinical Information Service
Townsville Hospital
PO Box 670
Townsville, QLD 4810
TSV-TTH-ROI@health.qld.gov.au
(07) 4433 1319
Woodford Correctional Centre
Information Access Unit
Caboolture Hospital
Locked Mail Bag 3
Caboolture, QLD 4510
Cab-HIS-IAU@health.qld.gov.au
(
07) 5433 8863
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application for Prison Health Records (Department of the Environment and Energy)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 8 May 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document