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TOHEALTHRECORDS APPLICATIONFORACCESS SECTION1:DETAILSOFAPPLICANT:(pleaseprint) Itwillhelpuslocatethedocumentsifyoucanprovideasmanydetailsaboutthedocumentsaspossible,including:inwhatnametheyareheld (Queensland Health)

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The TOHEALTHRECORDS APPLICATIONFORACCESS SECTION1:DETAILSOFAPPLICANT:(pleaseprint) Itwillhelpuslocatethedocumentsifyoucanprovideasmanydetailsaboutthedocumentsaspossible,including:inwhatnametheyareheld (Qu form is 2 pages long and contains:

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05/2021v4.0
METRONORTHHOSPITAL&HEALTHSERVICE
APPLICATIONFORACCESS
TOHEALTHRECORDS
ForOfficeUseOnly(AttachPatientIDLabel)
URN:
FamilyName:
GivenName(s):
Address:
DateofBirth:Sex:MFI
IfyouareapplyingforANOTHERPERSON’Srecordsthisisnotthecorrectapplicationform—pleaseusetheRight
toInformationandInformationPrivacyAccessApplicationform
SECTION1:DETAILSOFAPPLICANT:(pleaseprint)
Itwillhelpuslocatethedocumentsifyoucanprovideasmanydetailsaboutthedocumentsaspossible,including:inwhatnametheyareheld
(e.g.underamaidenname);thedate(s)oftreatment;andwheretheyareheld(e.g.RedcliffeHospital).
Title: FullName: DateofBirth:
Nameusedinrecords:
Note:Pleasecompleteifrecordsmaybeheldunderadifferentnamethanstatedabove,e.g.maidenname,allaliases
PostalAddress:
Suburb: Postcode:
Telephone(H): Telephone(W): Telephone(M):
EmailAddress:
Non‐groupemailaddresspreferred
PLEASEPRINTCLEARLY
SECTION2:DETAILSOFYOURREQUEST:
Wheredoyouthinkthedocumentsmaybelocated?
CabooltureHospital
RedcliffeHospital
ThePrinceCharlesHospital
KilcoyHospital
RoyalBrisbaneandWomen’sHospital
WoodfordOffenderHealthService
Surgical,TreatmentandRehabilitationService(STARS)
CommunityandOralHealthServices:
OralHealth:Site__________________
CommunityServices:Site________________________________________________
_______________________________
_____________________________________________________________________
Pleasetickallsitesthatapplytoyourapplication–foracompletelistofwhichacutehospitalsmanageeachsite’sinformationrequests,
pleaserefertotheAccesstoHealthRecordsInformationSheetavailableontheMetroNorthHospitalandHealthServicewebsite:
https://metronorth.health.qld.gov.au/about‐us/information‐access‐privacy/accessing‐health‐records
Pleaseprovidespecificanddetailedinformationaboutthedocumentsyouareseeking:
Iwouldlikeaccesstothefollowingsubjectmatterortypesofdocuments,e.g.operationreport,admissionrecords,dischargesummary:
ThedatesIwouldlikeyoutosearchwithinare,e.g.September2016–June2017:
Attachadditionalpages(ifnecessary)tofullydescribethedocumentsyouareseeking
Clear Form
05/2021v4.0
SECTION3:EVIDENCEOFIDENTITYANDAUTHORISATIONOFAGENT
EVIDENCEOFIDENTITY EvidenceofAuthorisationofAgent(ifapplicable)
Beforeaccesstopersonalinformationcanbegiven,youwill
needtoprovidecertifiedevidenceofyouridentity*,
includingchangeofnamedocumentswherethenameonour
recordsisdifferenttoyourcurrentname.
Ifyouarerequestingpersonalinformationonbehalfof
anotherperson,thewrittenconsentandcertifiedevidence
ofidentity*forthatpersonMUSTbeattached.
Acopyoftheidentificationdocumentisattached Acopyoftheconsentandevidenceofidentityisattached
OfficeUseOnly IdentifyConfirmed

Y

N Staffmemberverifyingidentity:
*YourevidenceofidentitydocumentmustbecertifiedbyaJusticeofthePeace,CommissionerforDeclarations,LawyerorNotaryPublicasa
truecopyoftheoriginal.Ifprovidingtheevidenceofidentitydocument/sbyemailacolourscannedcopymustbeprovided.
SECTION4:PROCESSINGOFYOURAPPLICATION
Dependingonthecontentsofyourrecords,yourapplicationmaybeprocessedundertheAdministrativeAccessto
HealthRecordProcedure(AA)ortheInformationPrivacyAct2009(IPAct).Contentssuchasmentalhealthrecords,
childprotectioninformationandsomeotherlimitedcircumstancesarerequiredtobeprocessedundertheIPAct.
Howlongwillmyapplicationtake?
InformationprocessedunderAAwillgenerallybeavailablewithin20businessdays.Applicationsprocessedunder
theIPActwillnormallybeavailablewithin25businessdays.Businessdaysdonotincludeweekendsorpublic
holidays.
Iagreeformyapplicationtobeprocessedunderwhichevermechanism(AAorIPAct)isappropriate.
SIGNED:____________________________________________________ DATE:_______________________
SECTION5:PREFERREDACCESSTYPEANDDELIVERYMETHOD(tickoneboxineachsectiononly)
Accesstype
ElectroniccopyonCD
(freeofcharge)
PhotocopyofDocuments
(chargesmayapply)
SecureEmail(viaKiteworks)
(freeofcharge)
Selectdeliverymethod
Registeredpost PickupbyApplicant  Collectionbyauthorisedperson
(pleasecompletecollectionauthorisationdetails
below)

Iauthorisethepersonnamedbelowtocollectrecordsonmybehalf:
Nameofauthorisedperson:________________________________
Addressofauthorisedperson:_______________________________
________________________________________________________
Signatureofapplicant:_____________________________________
Collectedby:
Signatureofauthorisedperson:_____________________________
InitialsofIAUofficerreleasingrecords:________________________

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TOHEALTHRECORDS APPLICATIONFORACCESS SECTION1:DETAILSOFAPPLICANT:(pleaseprint) Itwillhelpuslocatethedocumentsifyoucanprovideasmanydetailsaboutthedocumentsaspossible,including:inwhatnametheyareheld (Queensland Health)

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Completed 9 May 2022

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